HESI RN
Community Health HESI
1. A client presents at a community-based clinic with complaints of shortness of breath, headache, often uses a gasoline-powered pressure washer to clean equipment and farm buildings. Which type of poisoning is the most likely etiology of this client's symptoms?
- A. asbestos
- B. silica dust
- C. histoplasmosis
- D. carbon monoxide
Correct answer: D
Rationale: The correct answer is D, carbon monoxide poisoning. This client's symptoms of shortness of breath and headache are consistent with carbon monoxide exposure, which can result from using gasoline-powered equipment in poorly ventilated areas. Asbestos (choice A) is linked to respiratory issues but does not typically present with these acute symptoms. Silica dust (choice B) exposure is associated with lung damage, not the symptoms described. Histoplasmosis (choice C) is a fungal infection and would not typically manifest with the symptoms presented by the client.
2. Which of the following is NOT a phase of the menstrual cycle?
- A. Follicular phase
- B. Ovulatory phase
- C. Luteal phase
- D. Secretory phase
Correct answer: D
Rationale: The secretory phase is not considered a distinct phase of the menstrual cycle; it is actually part of the luteal phase. During the luteal phase, the endometrium thickens due to progesterone secretion, preparing for implantation. The follicular phase is characterized by follicle development, leading to ovulation. The ovulatory phase is when the mature egg is released from the ovary. Therefore, the secretory phase is the correct answer as it is not a standalone phase but a part of the luteal phase.
3. The client is weak from inactivity due to a 2-week hospitalization. In planning care for the client, which range of motion (ROM) exercises should the nurse include?
- A. Passive ROM exercises to all joints on all extremities four times a day.
- B. Active ROM exercises to both arms and legs two or three times a day.
- C. Active ROM exercises with weights twice a day, 20 repetitions each.
- D. Passive ROM exercises to the point of resistance and slightly beyond.
Correct answer: B
Rationale: Active ROM exercises are preferred over passive ROM to restore strength. Performing them on both arms and legs two or three times a day is effective in promoting muscle strength and mobility without the need for external assistance. Choice A is incorrect as passive ROM exercises may not help in restoring strength. Choice C is not recommended as using weights may be too strenuous for a weak client. Choice D is incorrect as passive ROM exercises to the point of resistance and slightly beyond may cause discomfort or injury to the weak client.
4. The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?
- A. Dorsogluteal site
- B. Ventrogluteal site
- C. Deltoid site
- D. Vastus lateralis site
Correct answer: D
Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.
5. A patient with acute congestive heart failure is receiving high doses of a diuretic. On assessment, the nurse notes flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. Suspecting hyponatremia, what additional signs would the nurse expect to note in this patient if hyponatremia were present?
- A. Dry skin
- B. Decreased urinary output
- C. Hyperactive bowel sounds
- D. Increased specific gravity of the urine
Correct answer: C
Rationale: In a patient with hyponatremia, hyperactive bowel sounds are expected due to increased gastrointestinal motility. Dry skin (Choice A) is not a typical sign of hyponatremia. Decreased urinary output (Choice B) is more commonly associated with conditions like dehydration or renal issues, not specifically hyponatremia. Increased specific gravity of the urine (Choice D) is a sign of concentrated urine, which is not a characteristic finding in hyponatremia.