HESI RN
HESI Community Health
1. Who is likely to have the most influence on these women's perceptions about their children's healthcare needs?
- A. husbands
- B. clinic healthcare provider
- C. older females
- D. tribal chief
Correct answer: C
Rationale: In many cultures, older women, such as grandmothers or aunts, hold significant influence over health-related decisions and practices within the family. They are often the ones consulted for advice on healthcare matters concerning children. Husbands (choice A) may have influence in other areas, but when it comes to healthcare decisions for children, older females are typically more influential. Clinic healthcare providers (choice B) may offer guidance, but the influence of older females within the community is usually stronger. Tribal chiefs (choice D) may hold authority but might not be as directly involved in individual healthcare decisions within families as older females.
2. The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?
- A. Hypercalcemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Hypomagnesemia.
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. When a client has a nasogastric tube to continuous suction, potassium loss through gastric fluids can lead to hypokalemia. Hypercalcemia (Choice A) is not typically associated with continuous suction. Hyponatremia (Choice C) involves sodium imbalance and is not directly related to nasogastric suction. Hypomagnesemia (Choice D) is not the primary concern in this situation, as potassium loss is more significant with gastric suction.
3. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?
- A. Apical pulse of 58 beats per minute.
- B. Serum potassium level of 3.0 mEq/L.
- C. Blood pressure of 140/90 mm Hg.
- D. Client reports seeing halos around lights.
Correct answer: D
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.
4. The nurse is preparing to administer a scheduled dose of digoxin (Lanoxin) to a client. Which assessment finding should the nurse report to the healthcare provider?
- A. Heart rate of 90 beats per minute.
- B. Serum potassium level of 4.0 mEq/L.
- C. Blood pressure of 130/80 mm Hg.
- D. Client reports seeing halos around lights.
Correct answer: D
Rationale: Seeing halos around lights is a symptom of digoxin toxicity, which should be reported to the healthcare provider. This visual disturbance is a serious adverse effect of digoxin and indicates potential toxicity. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal limits and do not indicate an immediate need for intervention related to digoxin administration.
5. The healthcare provider is assessing a client who has a nasogastric tube to low intermittent suction. Which finding indicates that the client may have developed hypokalemia?
- A. Muscle weakness and cramps.
- B. Nausea and vomiting.
- C. Constipation.
- D. Increased blood pressure.
Correct answer: A
Rationale: Muscle weakness and cramps are characteristic signs of hypokalemia, a condition marked by low levels of potassium in the blood. Potassium is essential for proper muscle function, and its deficiency can lead to muscle weakness and cramps. In the context of a client with a nasogastric tube to low intermittent suction, the loss of potassium through suctioning can contribute to the development of hypokalemia. Nausea and vomiting (choice B) are more commonly associated with gastrointestinal issues rather than hypokalemia. Constipation (choice C) is not a typical finding of hypokalemia; instead, it can be a sign of other gastrointestinal problems. Increased blood pressure (choice D) is not a direct manifestation of hypokalemia; in fact, low potassium levels are more commonly associated with decreased blood pressure.
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