the nurse is caring for a client with a history of peptic ulcer disease which of these findings would be most concerning to the nurse
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Nursing Elites

HESI RN

HESI Nutrition Exam

1. The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?

Correct answer: C

Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.

2. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to

Correct answer: D

Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.

3. 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.

4. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

5. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

Correct answer: A

Rationale: The correct answer is to avoid chocolate and cheese. MAO inhibitors can interact with tyramine-rich foods like these, potentially leading to severe hypertension. Choices B, C, and D are incorrect because taking frequent naps, taking the medication with milk, and avoiding walking without assistance are not relevant precautions associated with MAO inhibitors.

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