HESI RN
Community Health HESI
1. A school nurse is developing a program to address bullying among students. Which component is most important to include?
- A. education on the effects of bullying
- B. training for teachers on how to handle bullying incidents
- C. a peer mentoring program
- D. a zero-tolerance policy for bullying
Correct answer: B
Rationale: Training for teachers is the most important component to include in addressing bullying among students. Teachers play a crucial role in identifying, intervening, and preventing bullying incidents. By providing teachers with training on how to handle bullying, they can effectively address such situations, support victims, and educate students on appropriate behavior. While education on the effects of bullying (Choice A) is important, teachers need practical skills to intervene. Peer mentoring programs (Choice C) and zero-tolerance policies (Choice D) are valuable but may not be as effective without teachers being equipped to address bullying incidents directly.
2. A client with a history of hypertension is admitted with a blood pressure of 200/120 mm Hg. Which medication should the nurse prepare to administer?
- A. Metoprolol (Lopressor).
- B. Furosemide (Lasix).
- C. Lisinopril (Zestril).
- D. Nitroprusside (Nipride).
Correct answer: D
Rationale: The correct answer is D, Nitroprusside (Nipride). In this scenario of severe hypertension (200/120 mm Hg), a hypertensive emergency is present, requiring rapid reduction of blood pressure. Nitroprusside is a vasodilator that acts quickly to lower blood pressure in such emergencies. Options A, B, and C are incorrect: A) Metoprolol is a beta-blocker that lowers blood pressure but is not indicated for hypertensive emergencies requiring rapid reduction. B) Furosemide is a diuretic that helps with fluid retention but does not rapidly lower blood pressure. C) Lisinopril is an ACE inhibitor used for long-term management of hypertension, not for immediate reduction in hypertensive emergencies.
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. A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?
- A. Increased respiratory rate.
- B. Absence of breath sounds.
- C. Expiratory wheezes.
- D. Productive cough with green sputum.
Correct answer: B
Rationale: The correct answer is B: Absence of breath sounds. This finding can indicate a pneumothorax or severe asthma exacerbation, both of which require immediate intervention to ensure adequate ventilation and prevent further complications. Increased respiratory rate (choice A) is common in asthma exacerbations but may not always necessitate immediate intervention. Expiratory wheezes (choice C) are typical in asthma and may not always indicate a critical condition. A productive cough with green sputum (choice D) suggests a possible respiratory infection but does not warrant immediate intervention as much as the absence of breath sounds.
5. The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?
- A. Temperature of 99°F (37.2°C).
- B. Respiratory rate of 20 breaths per minute.
- C. Heart rate of 90 beats per minute.
- D. Fatigue.
Correct answer: C
Rationale: In a client with pneumonia, a heart rate of 90 beats per minute requires immediate intervention. Jugular vein distention indicates increased central venous pressure, suggesting possible complications like heart failure or fluid overload. Monitoring the heart rate closely and addressing any signs of heart failure promptly are crucial. A temperature of 99°F is within normal range and does not require immediate intervention. A respiratory rate of 20 breaths per minute is also normal. Fatigue is a common symptom in pneumonia but does not indicate an immediate need for intervention compared to the critical nature of jugular vein distention.
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