HESI RN
Community Health HESI Quizlet
1. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
- A. Elevate the affected leg on a pillow.
- B. Apply a warm compress to the affected leg.
- C. Perform passive range-of-motion exercises on the affected leg.
- D. Encourage the client to ambulate frequently.
Correct answer: A
Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.
2. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?
- A. Headache
- B. Prothrombin time (PT) of 15 seconds
- C. Elevated liver enzymes
- D. Peripheral edema
Correct answer: A
Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.
3. The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. Hemoglobin level
Correct answer: C
Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.
4. The programs aimed at achieving total reproductive health as a social goal at the national level are called:
- A. Family organization
- B. Family planning
- C. Reproductive care
- D. Reproductive health
Correct answer: D
Rationale: The correct answer is D, 'Reproductive health.' Reproductive health programs focus on ensuring overall well-being in relation to reproduction, including access to reproductive services, education, and healthcare. Choice A, 'Family organization,' does not specifically address health aspects related to reproduction. Choice B, 'Family planning,' is more focused on birth control and family size rather than the broader aspects of reproductive health. Choice C, 'Reproductive care,' is limited to the aspect of medical care and does not encompass the comprehensive approach of reproductive health programs.
5. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?
- A. I will use crutches to keep my weight off my knee
- B. I will stay home until a wheelchair is delivered
- C. I can use the trapeze bar and side rails on the bed to help me turn regularly
- D. I can put my full weight on my foot starting the day after surgery
Correct answer: A
Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.