the nurse is assessing a client who has just returned from surgery which of these findings requires the most immediate attention
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Nursing Elites

HESI RN

HESI Nutrition Proctored Exam Quizlet

1. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

2. After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate?

Correct answer: D

Rationale: The correct answer is D. A meal of turkey, sweet potato, green beans, milk, and an orange is low in sodium and suitable for a post-MI diet. Choice A includes a baked potato and canned beets, which are higher in sodium. Choice B includes canned salmon, which can be high in sodium. Choice C includes a bologna sandwich, which is also high in sodium compared to the other options.

3. A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?

Correct answer: C

Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.

4. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

5. The client is preparing for a myelogram. Which of the following statements by the client indicates a contraindication for this test?

Correct answer: B

Rationale: An allergy to shrimp is a contraindication for a myelogram because the contrast dye used in the procedure contains iodine, which can trigger allergic reactions in individuals allergic to shellfish. Choices A, C, and D are not contraindications for a myelogram. Inability to lie still for an extended period, claustrophobia, or a previous headache after a spinal tap are concerns that can be managed during the procedure but do not necessarily prevent the test from being performed.

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