a nurse checks a client who is on a volume cycled ventilator which finding indicates that the client may need suctioning
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Nursing Elites

HESI RN

HESI Nutrition Practice Exam

1. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

2. A client who is pregnant and has hyperemesis gravidarum is being taught about nutrition at home by a nurse. Which of the following statements indicate that the client understands the teachings?

Correct answer: C

Rationale: The correct answer is C. Eating crackers before getting out of bed can help manage nausea associated with hyperemesis gravidarum. Choice A is incorrect because drinking water with meals may exacerbate nausea. Choice B is incorrect as eating every 6 hours may not be frequent enough to combat nausea and vomiting. Choice D is incorrect because protein intake should not be limited during pregnancy, especially in cases of hyperemesis gravidarum.

3. The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?

Correct answer: C

Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.

4. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

5. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

Correct answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

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