HESI RN
HESI Nutrition Exam
1. The nurse is providing care for a client with a new tracheostomy. Which of these assessments is a priority?
- A. Checking the client's oxygen saturation level
- B. Monitoring the client's pain level
- C. Checking the tracheostomy site for signs of infection
- D. Monitoring the client's level of consciousness
Correct answer: C
Rationale: When caring for a client with a new tracheostomy, the priority assessment is checking the tracheostomy site for signs of infection. This is essential to detect early signs of complications such as infection, which can lead to serious issues. Monitoring oxygen saturation is important but not as critical as ensuring the tracheostomy site is free from infection. Pain assessment and level of consciousness are also important but secondary to assessing for signs of infection in this scenario.
2. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Client reports difficulty breathing
- B. Client reports shortness of breath when lying flat
- C. Client reports swelling in the feet and ankles
- D. Client reports a metallic taste in the mouth
Correct answer: A
Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.
3. What is included in the Quality of Care in reproductive health?
- A. Ensuring accessible services, privacy, confidentiality, and continuity of care.
- B. Providing reproductive health services only in urban areas.
- C. Ensuring that all women deliver in a hospital setting.
- D. Ensuring that reproductive health services are only provided by doctors.
Correct answer: A
Rationale: The correct answer is A. Quality of care in reproductive health encompasses ensuring accessible services, privacy, confidentiality, and continuity of care. These elements are crucial in providing comprehensive and effective reproductive health services. Choices B, C, and D are incorrect because they do not adequately address the holistic approach required for quality reproductive health care. Providing services only in urban areas limits accessibility, mandating hospital deliveries may not be suitable for all women, and restricting services to doctors only disregards the importance of a multi-disciplinary approach in reproductive health care.
4. In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy test?
- A. Threatened
- B. Imminent
- C. Missed
- D. Incomplete
Correct answer: C
Rationale: Dark brown vaginal discharge and a negative pregnancy test are characteristic of a missed abortion. In a missed abortion, the fetus has died, but the products of conception are retained in the uterus. This can lead to symptoms like dark brown vaginal discharge as the body tries to expel the nonviable pregnancy. A threatened abortion is characterized by vaginal bleeding without dilation of the cervix, and the pregnancy remains viable. Imminent abortion involves cervical dilation and effacement with no passage of tissue. In an incomplete abortion, only part of the products of conception are expelled, leading to persistent bleeding and cramping.
5. A client with gastroesophageal reflux is receiving teaching from a nurse. Which statement by the client indicates a need for further teaching?
- A. I will avoid eating after supper.
- B. I can drink coffee throughout the day.
- C. I drink milk when I get heartburn.
- D. I should not eat foods made with chocolate.
Correct answer: B
Rationale: The correct answer is B. Drinking coffee throughout the day can aggravate gastroesophageal reflux symptoms. Choices A, C, and D are correct statements that can help manage gastroesophageal reflux by avoiding late-night eating, not consuming trigger foods like chocolate, and using milk for relief when experiencing heartburn.