HESI RN
HESI Nutrition Proctored Exam Quizlet
1. The health care provider order reads 'aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?
- A. Hold the tube feeding and notify the provider
- B. Administer the tube feeding as scheduled
- C. Irrigate the tube with diet cola soda
- D. Apply intermittent suction to the feeding tube
Correct answer: A
Rationale: A pH of 10 indicates improper placement of the NG tube, requiring notification of the provider and holding the feeding. Choice B is incorrect because administering the tube feeding could lead to complications due to the improper placement. Choice C is incorrect as irrigating the tube with diet cola soda is not a standard practice for addressing this issue. Choice D is incorrect as applying intermittent suction does not address the problem of improper placement indicated by the high pH level.
2. Which of the following is a common complication of immobility?
- A. Muscle hypertrophy.
- B. Pressure ulcers.
- C. Bone fractures.
- D. Joint stiffness.
Correct answer: B
Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.
3. During the counseling session, you can also use the acronym, CLEAR. The letter E stands for:
- A. Encourage and assure the client of effective use of the method
- B. Explain how to use the method
- C. Tell the client about modern FP methods available, and discuss each in detail
- D. Explain all possible complications
Correct answer: B
Rationale: The correct answer is B: 'Explain how to use the method.' In the acronym CLEAR, the letter E specifically refers to explaining how to use the method, emphasizing the importance of providing clear instructions and guidance to the client. Choices A, C, and D are incorrect because they do not accurately represent what the letter E stands for in the given context. Encouraging and assuring the client, discussing modern FP methods in detail, and explaining possible complications are important aspects of counseling but do not align with the specific focus of 'Explain how to use the method,' as indicated by the acronym.
4. A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct answer: A
Rationale: The correct first nursing action when a client reports chest heaviness post-hip surgery is to gather more information through assessment. Inquiring about the onset, duration, severity, and precipitating factors of the heaviness is crucial to determine the cause. This approach helps the nurse to gather essential data to make an informed decision regarding the client's care. Administering oxygen (Choice B) may be indicated based on assessment findings, but it is crucial to assess first. Offering pain medication (Choice C) without further assessment is premature and may mask symptoms. Informing the physician (Choice D) should be done after a thorough assessment to provide comprehensive information for appropriate medical decision-making.
5. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct answer: A
Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).