HESI RN
Community Health HESI 2023
1. An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?
- A. propose the family seek assistance for care in the area of the reunion's location
- B. tell the caregivers to consider hiring a private duty nurse during the time away
- C. advise to have a case management evaluation of the client's home environment
- D. suggest social services be contacted to find a respite care facility for the client
Correct answer: D
Rationale: Respite care provides temporary relief for primary caregivers, allowing them to attend the reunion while ensuring the client is cared for.
2. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?
- A. Begin ambulation as soon as possible.
- B. Use continuous passive motion therapy to maintain joint mobility.
- C. Avoid putting weight on the affected leg.
- D. Apply ice packs to reduce pain and swelling.
Correct answer: B
Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.
3. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Test blood sugar every 2 hours using Accu-Chek
- B. Review signs of hyperglycemia with the family and client
- C. Administer insulin if the blood sugar is elevated
- D. Measure the client's urine output
Correct answer: D
Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.
4. Which of the following is the most important nursing action when administering a blood transfusion?
- A. Monitoring the patient's blood pressure.
- B. Monitoring the patient's temperature.
- C. Monitoring the patient's heart rate.
- D. Monitoring the patient's oxygen saturation.
Correct answer: A
Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.
5. A community health nurse is addressing the issue of substance abuse in the community. Which intervention should be prioritized?
- A. Providing education on the dangers of substance abuse
- B. Setting up a support group for individuals struggling with addiction
- C. Partnering with local law enforcement to reduce drug availability
- D. Creating a confidential hotline for reporting substance abuse
Correct answer: D
Rationale: Creating a confidential hotline for reporting substance abuse should be prioritized because it offers a safe and accessible way for individuals to seek help and support for their substance abuse issues. This intervention allows individuals to report their concerns anonymously and seek guidance without fear of judgment or repercussions. Providing education on the dangers of substance abuse (Choice A) is important but may not be as immediately impactful as offering a direct avenue for help. Setting up a support group (Choice B) is valuable but may not reach as many individuals or provide the same level of anonymity as a confidential hotline. Partnering with law enforcement (Choice C) is crucial for addressing substance abuse issues from a legal perspective but may not directly address the immediate needs of individuals seeking help.