HESI RN
HESI Nutrition Exam
1. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?
- A. Administer oxygen therapy
- B. Encourage the client to perform deep breathing exercises
- C. Raise the head of the bed
- D. Check the client's oxygen saturation level
Correct answer: D
Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.
2. The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.
3. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 28 breaths per minute
- C. Tidal volume of 300 ml
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.
4. A child with glomerulonephritis is asking for strawberries. What should the nurse do?
- A. Allow the child to eat strawberries.
- B. Restrict the child's diet.
- C. Give the child a low-protein diet.
- D. Increase the child's fluid intake.
Correct answer: B
Rationale: In glomerulonephritis, it is crucial to restrict the child's diet, particularly avoiding foods high in potassium like strawberries. Potassium restriction is essential because impaired kidney function in glomerulonephritis can lead to potassium retention, potentially causing hyperkalemia. Therefore, the nurse should restrict the child's diet to manage their condition effectively.
5. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?
- A. Jaundice.
- B. Ascites.
- C. Peripheral edema.
- D. Spider angiomas.
Correct answer: D
Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.