a client with a history of coronary artery disease is admitted with chest pain which of these findings would be most concerning to the nurse
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HESI RN

HESI Nutrition Proctored Exam Quizlet

1. A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?

Correct answer: B

Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.

2. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?

Correct answer: C

Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.

3. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?

Correct answer: C

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.

4. A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?

Correct answer: C

Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.

5. A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?

Correct answer: C

Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.

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