HESI LPN
Community Health HESI Questions
1. The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings?
- A. Refer the client to a nutritionist after providing health teaching about a low-sodium diet.
- B. Place the client in a recumbent position and call the paramedics for transport to the hospital.
- C. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service.
- D. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.
Correct answer: D
Rationale: The appropriate nursing action in response to significantly high blood pressure readings like 172/104 mm Hg and 164/98 mm Hg is to confirm the readings by taking the blood pressure in the other arm. This can help rule out any error or issue specific to that arm. The nurse should then schedule a healthcare practitioner's appointment for as soon as possible to further assess the client's condition and determine the appropriate intervention. Choice A is incorrect because solely referring the client to a nutritionist for a low-sodium diet without further assessment or confirmation of the blood pressure readings is premature. Choice B is incorrect as the client is already seated, and calling paramedics for immediate transport to the hospital is not warranted based solely on the blood pressure readings provided. Choice C is incorrect as stress may not be the sole reason for the high blood pressure readings, and further assessment is required before referring the client to counseling services.
2. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist the client to turn, deep breathe, and cough
- D. Monitor oxygen saturation
Correct answer: B
Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.
3. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct answer: A
Rationale: The correct answer is A. Focusing on the older children's needs during the initial days at home is crucial as it helps them feel secure and valued during the transition. This approach allows the children to adjust to the new family dynamics and feel included in the care of their newborn sister. Choice B is incorrect as it focuses on tasks rather than addressing the children's emotional needs. Choice C is not the initial step and does not involve directly addressing the children's needs. Choice D puts the decision-making burden on the children rather than providing guidance and support.
4. The public health RN is called to investigate a report of several cases of varicella at a daycare center. The daycare workers state that 5 children have been sent home over the past 2 weeks with fever and itchy blisters. Which intervention should the RN implement first?
- A. Validate that the children who were sent home had chickenpox.
- B. Ask the parents to take the child to see their pediatrician.
- C. Ask the parents to not send the child back to daycare until after 6 weeks.
- D. Tell the parents to send the child back to daycare; it was a mistake they were sent home.
Correct answer: A
Rationale: The correct answer is to validate that the children who were sent home had chickenpox. This is crucial in confirming the presence of varicella, which is necessary for appropriate management and control of the outbreak. Option B is not the first intervention because the focus initially is on verifying the cases within the daycare center. Option C is incorrect as it suggests a prolonged exclusion period without confirming the diagnosis. Option D is inappropriate and potentially harmful, as sending a child back without proper assessment can lead to further spread of the infection.
5. The occupational health nurse is completing a yearly self-evaluation. Which activity should the nurse document as an example of proficient performance criteria in professionalism?
- A. Contributes money to a professional society or organization
- B. Maintains chairmanship of the hospital nursing council
- C. Documents the nursing process in care management
- D. Develops policy initiatives that impact occupational health and safety
Correct answer: B
Rationale: Maintaining chairmanship of the hospital nursing council demonstrates leadership and professionalism. This role involves overseeing and leading nursing activities at the hospital, showcasing a high level of responsibility and professionalism. Choices A, C, and D do not directly relate to demonstrating professionalism. Contributing money to a professional society, documenting the nursing process, or developing policy initiatives, while valuable activities, do not directly reflect the same level of leadership and professionalism as maintaining chairmanship.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99