HESI RN
Community Health HESI
1. 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.
2. During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?
- A. suggest the client install a bedside commode
- B. assist the client in modifying the home environment
- C. refer the client to an occupational therapist
- D. educate the client on mobility aids
Correct answer: A
Rationale: The correct answer is to suggest that the client installs a bedside commode. This option provides an immediate solution to the client's difficulty accessing the bathroom. While modifying the home environment (Choice B) and referring the client to an occupational therapist (Choice C) are important steps, suggesting a bedside commode addresses the immediate need efficiently. Educating the client on mobility aids (Choice D) can be beneficial but may not be the most urgent action required in this scenario.
3. During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?
- A. suggest that the client hires a cleaning service
- B. assist the client in organizing the living space
- C. assess the client's risk for falls
- D. provide the client with information on home safety
Correct answer: C
Rationale: The correct first action for the nurse to take is to assess the client's risk for falls. A cluttered living environment and poor lighting are significant risk factors for falls in the elderly. By assessing the client's risk for falls, the nurse can identify potential hazards and implement appropriate interventions to prevent falls. Suggesting hiring a cleaning service or assisting in organizing the living space may address the symptoms but not the root cause of the fall risk. Providing information on home safety is important but should come after assessing the specific risk factors for falls in this scenario.
4. 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.
5. A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?
- A. Blurred vision.
- B. Shoulder pain.
- C. Abdominal pain.
- D. Rhinorrhea or otorrhea with halo sign.
Correct answer: D
Rationale: The correct answer is D: Rhinorrhea or otorrhea with halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear) are signs of a basilar skull fracture, indicating the need to assess for possible meningeal tears that manifest as a halo sign with cerebrospinal fluid (CSF) leakage from the ears or nose. Choices A, B, and C are incorrect because blurred vision, shoulder pain, and abdominal pain are not typically associated with a basilar skull fracture.
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