HESI RN
HESI Nutrition Exam
1. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?
- A. Assess the severity and location of the pain
- B. Obtain an order for an analgesic
- C. Reassure the client that this is not unusual for his age
- D. Encourage the client to increase activity
Correct answer: A
Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.
2. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing I.V. fluids rapidly as ordered
- B. Encouraging increased oral intake
- C. Restricting fluids
- D. Administering glucose-containing I.V. fluids as ordered
Correct answer: C
Rationale: The correct nursing intervention for a male client with SIADH is to restrict fluids. In SIADH, there is excess release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Restricting fluids helps prevent further dilutional hyponatremia by reducing water intake. Infusing I.V. fluids rapidly (choice A) would worsen the condition by adding more fluids, encouraging increased oral intake (choice B) is contraindicated as it adds more fluids, and administering glucose-containing I.V. fluids (choice D) is not a standard treatment for SIADH.
3. A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement?
- A. Position the head of the bed (HOB) flat.
- B. Withhold intravenous fluids.
- C. Administer a bolus of IV fluids.
- D. Give an antihypertensive medication.
Correct answer: D
Rationale: In a client with a completed ischemic stroke, an elevated blood pressure like 180/90 mm Hg requires immediate intervention to prevent further damage. Giving an antihypertensive medication is essential to reduce the risk of recurrent stroke or complications related to hypertension. Positioning the head of the bed flat, withholding IV fluids, or administering a bolus of IV fluids are not appropriate actions for managing elevated blood pressure in this scenario and may not address the underlying cause of the hypertension or prevent potential complications.
4. What is located on the rough endoplasmic reticulum?
- A. Microvilli
- B. Mitochondria
- C. Lysosomes
- D. Ribosomes
Correct answer: D
Rationale: The rough endoplasmic reticulum is studded with ribosomes, not microvilli, mitochondria, or lysosomes. Ribosomes are responsible for protein synthesis, making them an essential component of the rough endoplasmic reticulum.
5. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress. Administering morphine sulfate (Choice A) is not the priority in this case as it may cause further respiratory depression. Starting IV fluids (Choice B) may not address the immediate cyanosis and hyperpnea. Providing 100% oxygen by face mask (Choice D) can help with oxygenation but may not be as effective as placing the infant in a knee-chest position to improve blood flow dynamics.