a client with a history of asthma is admitted to the emergency department with difficulty breathing which of these assessments is the highest priority
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Nursing Elites

HESI RN

HESI Nutrition Exam

1. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

2. A nurse is reinforcing teaching with a client who has Crohn's Disease and is experiencing frequent cramping and diarrhea. Which of the following statements should the nurse include in the teaching?

Correct answer: A

Rationale: The correct answer is A. Increasing caloric intake by eating foods high in protein can help Crohn's Disease patients maintain their weight and manage symptoms. Choice B is incorrect because fresh fruits and vegetables may exacerbate symptoms due to their high fiber content. Choice C is incorrect as high-fat foods can be difficult to digest and may worsen symptoms. Choice D is incorrect because whole milk can be problematic for individuals with Crohn's Disease due to its high fat content.

3. A nurse is reinforcing teaching with a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select one that doesn't apply).

Correct answer: D

Rationale: The correct answer is D - Strawberries and bananas. Cottage cheese, milkshakes, and tuna fish are high in protein and calories, making them beneficial in preventing protein-energy malnutrition. However, strawberries and bananas are not as protein or calorie-dense compared to the other options, so they are not as effective in preventing malnutrition.

4. A nurse is assisting with the development of an education program for a community group about intake of vitamins and minerals in the diet. Which of the following foods should the nurse recommend as the best source of vitamin C?

Correct answer: B

Rationale: The correct answer is B: 1 medium orange. Oranges are well-known for being rich in vitamin C, an essential nutrient for immune function and skin health. While choices A, C, and D also contain some vitamin C, the medium orange provides a higher amount of this vitamin compared to a ½ cup of green pepper, ½ cup of cabbage, or a medium tomato.

5. A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?

Correct answer: D

Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.

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