HESI RN
HESI Community Health
1. When caring for a client with a chest tube, which intervention is most important to include in the plan of care?
- A. Maintain continuous suction on the chest tube.
- B. Clamp the chest tube during client movement.
- C. Ensure that the chest tube is clamped for at least 8 hours each day.
- D. Keep the collection chamber below the level of the chest.
Correct answer: D
Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.
2. When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
- A. Client appears anxious.
- B. Client's skin is warm and dry.
- C. S1 murmur auscultated in supine position.
- D. Client is resting quietly.
Correct answer: C
Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.
3. A client with chronic kidney disease is experiencing pruritus. Which intervention should the nurse include in the plan of care?
- A. Administer antihistamines as prescribed.
- B. Apply moisturizing lotion to the skin.
- C. Use cool water for bathing.
- D. Encourage a high-protein diet.
Correct answer: A
Rationale: Correct. Administering antihistamines as prescribed is the appropriate intervention for a client with chronic kidney disease experiencing pruritus. Antihistamines can help reduce pruritus by blocking histamine receptors, which are often prescribed for such clients. Choice B, applying moisturizing lotion, may help with dry skin but will not directly address pruritus. Choice C, using cool water for bathing, may provide some relief but does not target the underlying cause of pruritus. Choice D, encouraging a high-protein diet, is not directly related to managing pruritus in chronic kidney disease.
4. When developing a presentation on injury prevention for high school students in a health education class, which topic is most important for the nurse to include?
- A. Sports-related injuries
- B. Substance abuse
- C. Seat belt safety
- D. Pregnancy prevention
Correct answer: C
Rationale: The correct answer is C: Seat belt safety. This topic is crucial as it can significantly reduce the risk of injury or death in car accidents, which is a common cause of severe injuries among high school students. While sports-related injuries, substance abuse, and pregnancy prevention are important topics, seat belt safety directly addresses a preventable cause of injuries that can have immediate life-saving effects.
5. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?
- A. Amylase of 120 U/L.
- B. Lipase of 150 U/L.
- C. Calcium of 8.5 mg/dL.
- D. Blood glucose of 250 mg/dL.
Correct answer: D
Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.
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