HESI RN
HESI Maternity Test Bank
1. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
- A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
- B. Use a nipple shield to help the baby latch on.
- C. Try a different breastfeeding position.
- D. Have another person help the mother with breastfeeding.
Correct answer: A
Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding. Choice B, using a nipple shield, may not address the underlying issue causing the baby's difficulty latching. Choice C, trying a different breastfeeding position, can be attempted after the baby is calm and ready to latch. Choice D, having another person help, may not be necessary if the mother can be guided effectively on latching techniques.
2. The community health nurse believes that immunization rates in a lower socioeconomic section of the city are probably below the target set by the state health department. What action should the nurse take first to intervene with this health problem?
- A. join a political action group that focuses attention on the issue in the local news media
- B. partner with a local children's hospital in setting up free 'shot' clinics in the neighborhood
- C. review current epidemiological population data that might document a low immunization rate
- D. call a meeting of citizens to inform them of the importance of having their children immunized
Correct answer: C
Rationale: The most appropriate initial action for the community health nurse to take when addressing low immunization rates in a lower socioeconomic area is to review current epidemiological data. By reviewing this data, the nurse can gather evidence that documents the low immunization rate in the community. This information is crucial to support the need for targeted interventions to increase immunization rates. Choices A, B, and D involve actions that may be important at later stages of intervention but are not the first step. Joining a political action group, partnering with a hospital for clinics, or holding a community meeting are all valuable strategies, but they should be based on evidence obtained from reviewing epidemiological data to ensure targeted and effective interventions.
3. A client with heart failure is prescribed furosemide (Lasix). Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 100/60 mmHg
- C. Presence of a new murmur
- D. Crackles in the lungs
Correct answer: D
Rationale: The correct answer is D: Crackles in the lungs. Crackles indicate fluid overload in the lungs, a critical sign in a client with heart failure. This finding suggests that the furosemide may not be effectively managing the fluid balance, and immediate intervention is required. Choices A, B, and C are not immediate concerns in this scenario. A heart rate of 60 beats per minute, a blood pressure of 100/60 mmHg, and the presence of a new murmur are findings that may require monitoring or intervention but are not as urgent as crackles in the lungs in a client with heart failure.
4. A client with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). Which of the following interventions should the nurse implement first?
- A. Administer intravenous insulin
- B. Start an intravenous line and infuse normal saline
- C. Monitor serum potassium levels
- D. Obtain an arterial blood gas (ABG)
Correct answer: B
Rationale: The correct first intervention in the treatment of a client with diabetic ketoacidosis (DKA) is to start an intravenous line and infuse normal saline. This is essential for fluid resuscitation to restore intravascular volume and improve perfusion. Administering intravenous insulin can lead to further potassium depletion without first addressing dehydration and electrolyte imbalances. Monitoring serum potassium levels is important but should follow fluid resuscitation to avoid life-threatening hypokalemia. Obtaining an arterial blood gas (ABG) is necessary to assess the acid-base status but is not the initial priority when managing DKA.
5. The client is being educated by the nurse on home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL (3.3 mmol/L)
- B. 75 mg/dL (4.2 mmol/L)
- C. 108 mg/dL (6 mmol/L)
- D. 119 mg/dL (6.6 mmol/L)
Correct answer: A
Rationale: A blood glucose level of 59 mg/dL (3.3 mmol/L) is considered hypoglycemia, which is an abnormally low blood sugar level. This level requires immediate attention as it can lead to symptoms such as confusion, shakiness, and even loss of consciousness if left untreated. Choices B, C, and D have blood glucose levels within the normal range or slightly higher, indicating euglycemia or normal blood sugar levels, and not hypoglycemia.