the nurse is assessing a client who has just returned from surgery which of these findings requires the most immediate attention
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Nursing Elites

HESI RN

HESI Nutrition Proctored Exam Quizlet

1. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

2. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

3. A nurse is reinforcing teaching about foods that enhance iron absorption when consumed with nonheme iron with a client who has iron deficiency anemia. Which of the following foods should the nurse include in the teaching?

Correct answer: A

Rationale: The correct answer is A, Tomato juice. Tomato juice is high in vitamin C, which enhances the absorption of nonheme iron from foods. Vitamin C helps convert nonheme iron to a form that is easier for the body to absorb. Tea (choice B) contains tannins that can inhibit iron absorption. Milk (choice C) contains calcium, which can interfere with iron absorption. Dried beans (choice D) are a good source of nonheme iron but do not enhance iron absorption when consumed with nonheme iron.

4. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: Shaking the NPH insulin bottle hard can cause air bubbles and affect dosing accuracy; it should be rolled gently instead.

5. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

Correct answer: C

Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.

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