HESI RN
Community Health HESI
1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
- A. International normalized ratio (INR) of 1.0.
- B. Prothrombin time (PT) of 12 seconds.
- C. Partial thromboplastin time (PTT) of 60 seconds.
- D. International normalized ratio (INR) of 2.5.
Correct answer: D
Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.
2. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?
- A. Baked apples with raisins.
- B. Yogurt with fresh berries.
- C. Avocados and cheese.
- D. Fresh fruit salad.
Correct answer: B
Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.
3. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. Client with pneumonia who has a fever of 101.5°F
- B. Client who underwent knee surgery and needs dressing change
- C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
- D. Client with diabetes requesting insulin
Correct answer: C
Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.
4. The healthcare provider is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?
- A. Amylase
- B. Creatinine
- C. Blood urea nitrogen
- D. Bilirubin
Correct answer: D
Rationale: Bilirubin is a key serum laboratory value that is likely to be elevated in clients with jaundice. Jaundice is characterized by a yellowish discoloration of the skin and eyes due to an excess of bilirubin, a breakdown product of hemoglobin. Elevated amylase levels are associated with pancreatic conditions, not specifically jaundice. Creatinine and blood urea nitrogen are markers of kidney function and are not directly related to jaundice.
5. Which of the following interventions is most appropriate for a patient with left-sided heart failure?
- A. Administering IV fluids.
- B. Administering oxygen.
- C. Administering diuretics.
- D. Administering antihypertensives.
Correct answer: B
Rationale: Administering oxygen is the most appropriate intervention for a patient with left-sided heart failure because it helps improve oxygenation. In left-sided heart failure, the heart struggles to pump oxygen-rich blood to the body, leading to inadequate oxygen supply to tissues. Administering oxygen can help alleviate symptoms of hypoxia and reduce the workload on the heart. IV fluids (Choice A) may exacerbate heart failure by increasing fluid volume, diuretics (Choice C) are used to reduce fluid overload in heart failure, and antihypertensives (Choice D) are more suitable for managing hypertension, which may be a comorbidity in heart failure but are not the primary intervention for left-sided heart failure.