HESI quiz

Which action would the nurse take for a client who is 3 hours post operation for a subtotal gastrectomy, has an NG tube on low continuous suction and has abdominal distention and nausea

Instill 30ml of air into the NG tube

During the administration of TPN an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. Which nursing intervention is the priority at this time

Interrupt the clients infusion and notify the health care provider

A client who had a choledochostomy is returned to the surgical unit with a T tube in place. Which intervention is the priority when caring for this client

Protecting the abdominal skin from bile drainage

Which action would the nurse perform to help prevent the possibility of choking in a client who recently experienced a stroke

Provide thickened liquids at meal time

Which statement made by the nurse is correct regarding total parenteral nutrition

"total parenteral nutrition must be administered through a central intravenous catheter"

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring which blood glucose level should the nurse identify as hypoglycemia

68 mg/dl (3.8 mmol/L)

How does the amount of hemoglobin in the flood affect oxygenation

A low hemoglobin level causes reduced oxygen carrying capacity

Which nursing intervention is most appropriate for ensuring that the client has undergone gastrostomy as a means of managing esophageal cancer gets balanced nutrition

Administering tube feedings

Which is the best communication technique for the nurse to use when beginning to teach the client about restricted diet

Ask what the client knows about the diet that was prescribed

Which intervention would the nurse plan to health the health care team address inadequate nutrition for a client with oral cancer

Assess daily weights evaluate swallowing measure nutritional intake monitor intake and output ensure mouth care before and after meals

Which food would the nurse instruct a client on a mechanical soft diet to eat

Bananas Mashed potatoes Smoked salmon

An unconscious toddler requires intermittent nasogastric feedings. When would the nurse check the placement of the tube

Before each feeding

Which assessment is important for the nurse to monitor in a client receiving TPN

Blood glucose

Which information would be the most important for the nurse to explain during a nutrition class for a group of clients with CHF

Choosing fresh or frozen vegetables instead of canned ones

Which action represents effective nursing management of a clients nasogastric tube in the immediate postoperative period after gastroduodenstomy

Carefully monitoring the NG tube to ensure that the tube is patent and the suction is working

Which action provides evidence that a family member is effectively managing the care for a homebound client with percutaneous endoscopic gastrostomy (PEG) tube?

The head of the bed remains elevated after the feeding

A nurse is caring for an underweight adolescent girl with a diagnosis of anorexia nervosa. Which characteristic of girls is commonly found when obtaining a health history

Fatigue Secondary amenorrhea

Which food would the nurse expect to be restricted by the dietician for a client on a low sodium diet

Ham Cheese Hot dogs Dried fruit Lunch Meats

Which food would the nurse offer to a client who is prescribed a clear liquid diet after surgery

Jell-o Broth Ginger Ale

Which element of nursing care would the nurse implement fro a client after gastric surgery who has a nasogastric tube in place

Monitor for signs of electrolyte imbalance

The nurse asked the unlicensed assistive personnel (UAP) to ambulate a client who has a NT tube to low intermittent suction by disconnecting the tube from suction and keeping the tube clamped and above the stomach. The nurse returns to the room after the ambulation to verify tube placement. Which finding indicates a need to discuss the care with the UAP

Nasogastric tube hooked to 150 mm Hg suction

Which would the nurse do first for a client with a newly inserted nasogastric tube and a prescription to institute the feeding immediately?

Obtain an xray to verify that the tube is in the stomach

Which intervention will the nurse use to prevent aspiration pneumonia in a client receiving bolus enteral tube feedings

Perform oral hygiene frequently Measure residual before each feeding Check tube position before administrating the feeding Administer the tube feeding with the head of bed elevated Keep head of bed elevated for 30 minutes after the feeding

Which complication would the nurse monitor for development in a client receiving TPN?

Phlebitis Infection

In which position would a child who finished a feeding though a nasogastric tube, he placed to help ensure retention of the feeding and prevent aspiration

Semi fowler

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. Which nursing intervention will best help to meet this clients nutritional needs

Stay with the client during meals

Which item would the nurse removed from the food tray of a client with suspected upper gastrointestinal bleeding

Strawberry Jell-o

Which statement by the client indicates understanding of the nurses' teaching regarding the purpose of TPN after extensive colon surgery

TPN provides total nutrition when gastrointestinal function is questionable

Which action would the nurse take when the client vomits 90 mL of bile colored fluid after abdominal surgery and has a nasogastric tube in place

check the potency of the tube

Which response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion

dyspnea

The nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which food identified by the client indicates that teaching

milk, eggs, cheese

Which item would be specifically included on a full liquid diet

refined cooked cereal

While screening school students for nutritional needs the nurse obtains a Childs height of 4ft, 11in and a weight of 98lbs calculate the Childs body mass index

19.8

A garage feeding is prescribed for an infant. How would the nurse determine the length of tube needed to reach the stomach

A measurement is made from earlobe to nose and then to the epigastric area

Which teaching would a nurse include with a client who is learning how to self administer gastrostomy tube feedings

Administering water after the feeding is completed

Which statement made by the client after attending a class on nutrition indicates an understanding of the importance of essential amino acids

Amino acids must come from the diet because they cannot be synthesized in the body

Which serious complication would the nurse attempt to prevent in a client with a NG tube

Aspiration pneumonia

Which food would the nurse include in teaching for a client who is deficient in vitamin A

Carrots Leafy greens

After surgery, total parenteral nutrition is instituded via a central venous infusion. After 4 hours of the infusion, the client complains of nausea, fatigue, and a headache. The hourly urine output is twice the amount of the previous hour. After contacting the primary health care provider, which action would the nurse take next

Check the serum glucose level

Which measure would the nurse take to prevent aspiration when caring for a client receiving enteral feedings

Elevate the HOB 30-45 degrees

When teaching a client, the nurse explains that the risk for which neonatal disorder can be lowered with intake of folic acid

Neural tube defects

During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk for infection and other problems, which action would the nurse take

Provide oral supplements

The plan of care for a client with an intestinal tube includes a prescription to instill 30ml of normal saline into the tube as needed to maintain latency. Which would the nurse do when considering the normal saline that is instilled

Record the 30ml on the intake and output record

Which diet prescribed for the morning of an elective major surgery would a nurse be concerned about and contact the surgeon

Regular diet Full liquid diet

Which food selected by the client with a serum albumin level of 2.8 g/dl indicates that the nurse's dietary teaching was successful

Sliced turkey

The nurse explains to the abdominal surgical client that a progressive post surgical diet is characterized by which progressive alterations

Texture and digestibility of food

A client is being prepared for surgery to have placement of a PEG. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. Which explanation would the nurse give

There is less chance of aspiration

When a client with acute kidney disease questions the need for a preteen restricted diet, which response would the nurse make>

This diet supplies only essential amino acids and reduces the amount of metabolic waste products, which decreases stress on the kidneys

Which response would be given by a nurse to a client with dysphagia who states that swallowing can be more easily accomplished with the head tilted back quickly

Tilting the head back actually makes swallowing more difficult and increases the risk for aspiration

Which prescription would a nurse anticipate for a client with decreased fat absorption due to taking several antibiotic medications for a prolonged time

Water soluble forms of vitamins A and E