HESI RN
Community Health HESI
1. The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
2. The nurse is planning an immunization campaign targeting the children of migrant farm workers in the community. Which data should the nurse review before exploring solution options when developing this program plan?
- A. uncertain risks
- B. potential outcomes
- C. priority of solutions
- D. target population data
Correct answer: D
Rationale: Correct. Before designing an immunization campaign for the children of migrant farm workers, the nurse should review target population data. This includes understanding the specific demographics, health needs, and challenges faced by this population to create a tailored and effective program. Reviewing uncertain risks (choice A) may not provide actionable insights for program development. Considering potential outcomes (choice B) is important but comes after understanding the target population. Evaluating the priority of solutions (choice C) is premature without knowing the specific characteristics and needs of the target population.
3. A client with type 2 diabetes mellitus is admitted with hyperosmolar hyperglycemic state (HHS). Which laboratory result requires immediate intervention?
- A. Serum osmolality of 320 mOsm/kg.
- B. Serum glucose of 600 mg/dL.
- C. Serum potassium of 4.5 mEq/L.
- D. Serum sodium of 140 mEq/L.
Correct answer: B
Rationale: A serum glucose level of 600 mg/dL is extremely high in a client with hyperosmolar hyperglycemic state (HHS) and poses a significant risk of serious complications such as dehydration, coma, and electrolyte imbalances. Rapid intervention is crucial to normalize the glucose level and prevent further deterioration. Serum osmolality of 320 mOsm/kg, serum potassium of 4.5 mEq/L, and serum sodium of 140 mEq/L, while important to monitor in HHS, do not represent an immediate life-threatening condition that requires urgent intervention compared to the critically high glucose level.
4. The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?
- A. Hypercalcemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Hypomagnesemia.
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. When a client has a nasogastric tube to continuous suction, potassium loss through gastric fluids can lead to hypokalemia. Hypercalcemia (Choice A) is not typically associated with continuous suction. Hyponatremia (Choice C) involves sodium imbalance and is not directly related to nasogastric suction. Hypomagnesemia (Choice D) is not the primary concern in this situation, as potassium loss is more significant with gastric suction.
5. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct answer: B
Rationale: Reverse isolation precautions protect the client from exposure to microorganisms from others.
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