HESI RN
Community Health HESI Quizlet
1. A client who is receiving total parenteral nutrition (TPN) has an elevated blood glucose level. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer insulin as prescribed.
- C. Notify the healthcare provider.
- D. Check the TPN infusion rate.
Correct answer: D
Rationale: The correct first action for a client receiving TPN with an elevated blood glucose level is to check the TPN infusion rate. Elevated blood glucose levels in clients receiving TPN can be due to incorrect infusion rates leading to increased glucose delivery. By checking the TPN infusion rate, the nurse can verify if the rate is appropriate and make necessary adjustments. Stopping the TPN infusion abruptly could lead to complications from sudden nutrient deprivation. Administering insulin as prescribed may be necessary but should come after ensuring the correct TPN infusion rate. Notifying the healthcare provider is important but addressing the immediate need to check the infusion rate takes priority to manage hyperglycemia effectively.
2. A client taking fexofenadine (Allegra) is scheduled for allergy skin testing and tells the nurse in the healthcare provider's office that a dose was taken this morning. The nurse determines that:
- A. The client should reschedule the appointment.
- B. A lower dose of allergen will need to be injected.
- C. A higher dose of allergen will need to be injected.
- D. The client should have the skin test read a day later than usual.
Correct answer: A
Rationale: Fexofenadine, an antihistamine, can cause false-negative readings in allergy skin testing and should be discontinued 3 days prior. Therefore, the client should reschedule the appointment to ensure accurate test results.
3. A community health nurse is addressing the issue of elder abuse in the community. Which intervention should be prioritized?
- A. providing education on the signs of elder abuse
- B. setting up a support group for elder abuse survivors
- C. partnering with local law enforcement to increase patrols
- D. creating a confidential hotline for reporting abuse
Correct answer: D
Rationale: The prioritized intervention for addressing elder abuse in the community should be the creation of a confidential hotline for reporting abuse. A confidential hotline offers a safe and accessible way for individuals to report elder abuse and seek help promptly. Providing education on the signs of elder abuse (Choice A) is important but may not directly address immediate reporting and intervention needs. Setting up a support group for elder abuse survivors (Choice B) is beneficial for emotional support but may not address the primary need for reporting abuse. Partnering with local law enforcement to increase patrols (Choice C) focuses on prevention rather than providing a direct reporting mechanism for victims.
4. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?
- A. Elevate the right leg to reduce swelling.
- B. Loosen any restrictive dressings on the leg.
- C. Prepare the client for emergency surgery.
- D. Administer pain medication as prescribed.
Correct answer: B
Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.
5. An adult client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?
- A. Malignancy
- B. Infection
- C. Benign cyst
- D. Lymphadenitis
Correct answer: A
Rationale: The findings of a large, non-tender, hardened lymph node, especially in the absence of overlying tissue inflammation, are indicative of malignancy. These characteristics raise suspicion for cancer, prompting the need for further investigation. Choice B, Infection, is incorrect because infection would typically present as a tender and possibly swollen lymph node. Choice C, Benign cyst, is incorrect as cysts are usually soft and movable. Choice D, Lymphadenitis, is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes in response to an infection.