Hesi module questions and answers with rationale

A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: A Eat foods high in calories and fat B Lie down for at least 20 minutes after meals C Eat carbohydrates such as cereals, rice, and pasta Correct D Consume primarily soups and liquids at mealtimes Incorrect
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea.
Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review measures to ease and prevent nausea and vomiting if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points.
2.ID: 0A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? A Clonus is present. B Magnesium level is 10 mg/dL (4.11 mmol/L) C Deep tendon reflexes are absent. D The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent.
Test-Taking Strategy: Use the process of elimination and focus on the strategic words “medication is effective.” Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review the expected assessment findings for a client receiving magnesium sulfate if you had difficulty with this question.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Evidence, Perfusion
HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 594-595). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
3.ID: 0A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: A Vitamin K B Protamine sulfate C Calcium gluconate Correct