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. A client with a diagnosis of hypothermia is being admitted to the hospital by a nurse. Which of the following signs does the nurse anticipate that this client will exhibit?
- A. Increased heart rate and increased blood pressure
- B. Increased heart rate and decreased blood pressure
- C. Decreased heart rate and increased blood pressure
- D. Decreased heart rate and decreased blood pressure
Correct answer: D
Rationale: Hypothermia decreases the heart rate and blood pressure due to reduced metabolic needs of the body. With lower metabolic demands, the heart's workload decreases, leading to reductions in both heart rate and blood pressure. Choices A, B, and C are incorrect because hypothermia typically results in a decrease in heart rate and blood pressure, not an increase.
3. The nurse obtains a pulse rate of 89 beats/min for an infant before administering digoxin (Lanoxin). What action should the nurse take?
- A. Administer the medication.
- B. Hold the medication and contact the healthcare provider.
- C. Double the dose.
- D. Increase fluid intake.
Correct answer: B
Rationale: The correct answer is to hold the medication and contact the healthcare provider. Bradycardia (pulse rate less than 100 beats/minute) is an early sign of digoxin toxicity. It is essential to withhold digoxin and notify the healthcare provider to prevent potential adverse effects. Administering the medication (Choice A) could exacerbate the toxicity. Doubling the dose (Choice C) is inappropriate and dangerous. Increasing fluid intake (Choice D) is not indicated in this situation and does not address the issue of digoxin toxicity.
4. A healthcare professional is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted as the most specific indicator of this disease?
- A. Hemoglobin
- B. Serum bilirubin
- C. Blood urea nitrogen (BUN)
- D. Erythrocyte sedimentation rate (ESR)
Correct answer: B
Rationale: Serum bilirubin is the most specific indicator of hepatitis as it reflects liver dysfunction. Hemoglobin, blood urea nitrogen (BUN), and erythrocyte sedimentation rate (ESR) are not specific to hepatitis. Hemoglobin measures the oxygen-carrying capacity of red blood cells, BUN evaluates kidney function, and ESR is a nonspecific marker of inflammation or infection.
5. The client with newly diagnosed diabetes mellitus is receiving education from the nurse on managing blood glucose levels. Which statement indicates a need for further teaching?
- A. I will monitor my blood glucose levels regularly.
- B. I can eat whatever I want as long as I take my medication.
- C. I should exercise regularly to help control my blood sugar.
- D. I will rotate my injection sites to avoid tissue damage.
Correct answer: B
Rationale: Choice B indicates a need for further teaching because it suggests that the client can eat whatever they want as long as they take their medication, which is incorrect. Clients with diabetes mellitus need to follow a healthy and balanced diet in addition to taking their medication to effectively manage blood glucose levels. Choices A, C, and D are correct statements for managing diabetes. Monitoring blood glucose levels regularly, engaging in regular exercise to help control blood sugar, and rotating injection sites to avoid tissue damage are all important aspects of diabetes management.