HESI RN
HESI Community Health
1. The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
- A. Note in the student records that the second dose of the MMR vaccine should be administered prior to entering first grade
- B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed
- C. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year
- D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children
Correct answer: C
Rationale: The correct intervention for the school nurse is to contact kindergarten parents to remind them that the second dose of the MMR vaccine is due at the start of the school year. This approach directly addresses the issue of incomplete vaccination coverage and ensures that children receive the complete vaccination on time. Choice A is incorrect as it only notes the need for the second dose without actively engaging parents. Choice B is not as effective as directly contacting parents and may lead to delays in completing the vaccination series. Choice D, while promoting immunization, does not directly address the current situation of incomplete MMR vaccination among the kindergarten students.
2. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?
- A. Clamp the chest tube for 30 minutes every 2 hours.
- B. Milk the chest tube to ensure patency.
- C. Keep the drainage system at the level of the chest.
- D. Ensure that the chest tube is not clamped or kinked.
Correct answer: D
Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.
3. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning effectively?
- A. Continuous bubbling in the water-seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation (tidaling) in the water-seal chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct answer: B
Rationale: Intermittent bubbling in the suction control chamber is the correct observation indicating effective functioning of the chest tube. This bubbling signifies that the suction system is working correctly and maintaining the desired negative pressure in the pleural space. Continuous bubbling in the water-seal chamber suggests an air leak, which is not a normal finding. No fluctuation (tidaling) in the water-seal chamber may indicate a blockage or lack of communication between the pleural space and the water-seal, which is not ideal. Drainage of clear, pale yellow fluid from the chest tube is a normal finding, but it does not specifically indicate the effectiveness of the chest tube function.
4. While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?
- A. review the child's medical folder for a list of allergies
- B. instruct the child's parents to begin treatment
- C. advise the child's parents to obtain a medical evaluation of the child
- D. none of the above
Correct answer: C
Rationale: The correct action for the nurse to take is to advise the child's parents to obtain a medical evaluation of the child. This is important because a medical professional needs to properly diagnose and treat the brownish thickening observed on the child's neck. Reviewing the child's medical folder for allergies (Choice A) is not appropriate in this situation as it does not address the specific concern. Instructing the child's parents to begin treatment (Choice B) without a proper diagnosis can be harmful and ineffective. Choosing 'none of the above' (Choice D) is not the best option when a potential health issue is identified; seeking a medical evaluation is the most appropriate course of action.
5. An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?
- A. notify her parents
- B. refer her for prenatal care
- C. teach breastfeeding methods
- D. offer nutritional instructions
Correct answer: B
Rationale: The correct answer is to refer her for prenatal care. Prenatal care is essential to monitor the health of both the mother and the fetus during pregnancy. While notifying her parents may be important for support and involvement, the priority is ensuring the adolescent receives medical care. Teaching breastfeeding methods and offering nutritional instructions are important but are not the immediate priority in this situation where prenatal care is urgently needed.
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