a nurse is caring for four clients the nurse should observe which of the following clients for a risk of vitamin b6 deficiency
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Nursing Elites

HESI RN

Nutrition HESI Practice Exam

1. A nurse is caring for four clients. The nurse should observe which of the following clients for a risk of vitamin B6 deficiency?

Correct answer: B

Rationale: Chronic alcohol use disorder can lead to vitamin B6 deficiency due to impaired absorption and increased excretion of the vitamin. While clients with cystic fibrosis may be at risk for fat-soluble vitamin deficiencies, such as vitamins A, D, E, and K, they are not specifically at high risk for vitamin B6 deficiency. Clients taking phenytoin are at risk for folate deficiency, not vitamin B6. Clients prescribed rifampin for tuberculosis are at risk for vitamin D deficiency, not vitamin B6.

2. After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.

3. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first?

Correct answer: B

Rationale: In cases of preeclampsia with increasing blood pressure, the priority action for the nurse is to have the client turn to the left side. This position helps improve blood flow to the placenta and fetus, reducing the risk of complications. Checking the protein level in urine (Choice A) is important for assessing preeclampsia but not the immediate priority when blood pressure is increasing. Taking the temperature (Choice C) is not directly related to addressing increased blood pressure in preeclampsia. Monitoring urine output (Choice D) is essential but not the first action to take when blood pressure is rising.

4. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Correct answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

5. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

Correct answer: D

Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.

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