HESI RN
Community Health HESI
1. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. To bond with the baby.
- B. To help the baby latch on better.
- C. To stimulate contraction of the uterus.
- D. To promote milk production.
Correct answer: C
Rationale: The correct answer is C: 'To stimulate contraction of the uterus.' After delivery, breastfeeding helps in stimulating the release of oxytocin, which triggers the contraction of the uterus. This contraction is crucial to prevent uterine hemorrhage and facilitate the involution process. Choices A, B, and D are incorrect. While breastfeeding can indeed help in bonding with the baby and promoting milk production, in the immediate postpartum period after a Cesarean section, the priority is to ensure uterine contraction to prevent complications.
2. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
- A. International normalized ratio (INR) of 1.0.
- B. Prothrombin time (PT) of 12 seconds.
- C. Partial thromboplastin time (PTT) of 60 seconds.
- D. International normalized ratio (INR) of 2.5.
Correct answer: D
Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.
3. 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.
4. A public health nurse is planning a vaccination clinic for a rural community. Which vaccine should the nurse prioritize for adults in this area?
- A. hepatitis A
- B. influenza
- C. varicella
- D. measles, mumps, rubella (MMR)
Correct answer: B
Rationale: The correct answer is 'B: influenza.' Influenza vaccination is crucial for adults, particularly in rural areas where access to healthcare may be limited. Influenza can cause serious illness and complications, and vaccination helps protect individuals and prevent the spread of the virus. While vaccines for hepatitis A, varicella, and measles, mumps, rubella (MMR) are important, prioritizing influenza vaccination in this scenario is essential due to its seasonal prevalence and potential impact on public health. Hepatitis A and varicella vaccines are also important but may not be as immediately critical for this population. MMR vaccine is typically administered in childhood, so it is not the priority for adults in this scenario.
5. During a 2-week postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?
- A. have the client transported via ambulance to the hospital
- B. recheck the client's vital signs in 30 minutes
- C. instruct the client to drive to the hospital for admission
- D. assess the client's current symptoms
Correct answer: A
Rationale: The client is presenting with signs of a potential postoperative complication, such as fever, low blood pressure, and tachycardia, which could indicate sepsis or another serious issue. These symptoms require immediate hospital evaluation and management. Option B of rechecking vital signs in 30 minutes could delay crucial intervention in a potentially life-threatening situation. Option C is unsafe as the client should not drive herself due to her condition. Option D is vague and does not address the urgency of the situation.
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