HESI RN
Community Health HESI Quizlet
1. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
- A. Supine with the foot of the bed raised.
- B. On the left side with legs elevated.
- C. On the right side with legs elevated.
- D. Prone with head elevated.
Correct answer: A
Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.
2. Discuss the anatomical/physiological changes in pregnancy related to the breasts.
- A. Breast tenderness increases, circulatory supply to the breasts increases, leading to breast enlargement, and colostrum secretion occurs.
- B. Breast tenderness decreases, and there is no significant change in breast size.
- C. Breast changes include decreased tenderness and reduced circulatory supply.
- D. Breasts do not undergo significant changes during pregnancy.
Correct answer: A
Rationale: During pregnancy, the breasts undergo significant anatomical and physiological changes. These changes include increased breast tenderness, an increase in circulatory supply to the breasts, resulting in breast enlargement, and the secretion of colostrum. Choice B is incorrect as breast tenderness actually increases during pregnancy. Choice C is incorrect as the circulatory supply to the breasts increases rather than reduces. Choice D is incorrect as breasts do undergo notable changes during pregnancy.
3. The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?
- A. Encourage diaphragmatic breathing
- B. Increase the client's oxygen flow rate
- C. Have the client perform range of motion exercises
- D. Place the client in a supine position
Correct answer: A
Rationale: Encouraging diaphragmatic breathing is crucial in clients with COPD as it helps improve lung expansion and oxygen exchange, promoting more effective breathing. This intervention aids in reducing dyspnea and enhancing ventilation. Increasing the client's oxygen flow rate may not be appropriate and can potentially worsen hypercapnia in individuals with COPD. Performing range of motion exercises and placing the client in a supine position do not directly address the breathing difficulties associated with COPD exacerbation.
4. A healthcare professional is reviewing the medication orders for a client with hypothyroidism. Which of the following medications should the healthcare professional question?
- A. Levothyroxine
- B. Amiodarone
- C. Calcium supplements
- D. Aspirin
Correct answer: B
Rationale: The correct answer is B: Amiodarone. Amiodarone can affect thyroid function and potentially worsen hypothyroidism, so its use should be carefully considered or questioned in clients with this condition. Levothyroxine (Choice A) is the mainstay therapy for hypothyroidism and should not be questioned in this scenario. Calcium supplements (Choice C) are not typically contraindicated in clients with hypothyroidism and may be needed if there is a deficiency. Aspirin (Choice D) is not directly related to thyroid function and is not a medication that would typically be questioned in a client with hypothyroidism.
5. The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?
- A. Clotting time
- B. Uric acid level
- C. Potassium level
- D. Blood glucose level
Correct answer: B
Rationale: The correct answer is B, Uric acid level. Busulfan can cause an increase in uric acid levels, leading to hyperuricemia, renal stones, and acute renal failure. Monitoring uric acid levels is crucial to detect and manage potential complications associated with busulfan therapy.