HESI RN
Community Health HESI
1. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
2. A client with chronic renal failure is prescribed a low-protein diet. The nurse should explain to the client that the purpose of this diet is to:
- A. Prevent fluid overload.
- B. Reduce the workload on the kidneys.
- C. Prevent dehydration.
- D. Maintain electrolyte balance.
Correct answer: B
Rationale: The correct answer is B: 'Reduce the workload on the kidneys.' A low-protein diet is prescribed for clients with chronic renal failure to decrease the production of urea and other nitrogenous wastes, which can accumulate in the body when the kidneys are not functioning properly. This reduction in protein intake helps to lessen the burden on the kidneys, as they may have difficulty in filtering and excreting waste products. Choice A is incorrect because fluid overload is more related to restrictions in fluid intake rather than protein intake. Choice C is incorrect as a low-protein diet does not directly prevent dehydration. Choice D is incorrect because while electrolyte balance is essential in renal failure, the primary purpose of a low-protein diet is to reduce the workload on the kidneys by limiting the production of waste products.
3. A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effects, he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?
- A. Anxiety and restlessness
- B. Increased bowel movements
- C. Abdominal cramping
- D. Fever and chills
Correct answer: A
Rationale: The correct answer is A: Anxiety and restlessness. Abruptly stopping corticosteroids can cause adrenal insufficiency, leading to symptoms such as anxiety and restlessness. These symptoms indicate a potential serious complication that requires immediate intervention. Increased bowel movements and abdominal cramping are common side effects of ulcerative colitis and may not warrant immediate intervention. Fever and chills are not typically associated with adrenal insufficiency caused by corticosteroid withdrawal.
4. When reinforcing information about the use of corticosteroids in treating asthma in children, which statement indicates that the parent understands the teaching?
- A. My child should take the medication only when experiencing symptoms.
- B. I will rinse my child's mouth after each use of the inhaler.
- C. I should discontinue the medication if my child seems better.
- D. Corticosteroids are used for quick relief during an asthma attack.
Correct answer: B
Rationale: Rinsing the mouth after using corticosteroid inhalers is crucial as it helps prevent oral thrush, a common side effect associated with these medications. This practice reduces the risk of developing fungal infections in the mouth and throat, maintaining optimal oral health during asthma treatment.
5. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, nurse Sharmaine would be most accurate in stating:
- A. The test needs to be repeated following a 12-hour fast.
- B. It appears you aren't following the prescribed diabetic diet.
- C. It tells us about your sugar control for the last 3 months.
- D. Your insulin regimen needs to be significantly altered.
Correct answer: C
Rationale: The correct answer is C. Glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 3 months. This test is used to assess long-term blood sugar control in individuals with diabetes. Choice A is incorrect because fasting is not required for an HbA1c test. Choice B is judgmental and not supported by the information provided. Choice D is not the most accurate statement to make based on the HbA1c result; adjusting insulin would depend on a more comprehensive assessment of the client's overall diabetes management.