HESI RN
Maternity HESI Quizlet
1. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
- A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
- B. Pyloric obstruction causes reflux and projectile hematemesis.
- C. Partial imperforated anal opening limits passage of stools.
- D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.
Correct answer: A
Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.
2. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?
- A. Increased oxygen saturation of 96%.
- B. Oxygen saturation of 89%.
- C. Respiratory rate of 20 breaths per minute.
- D. Decreased heart rate of 70 beats per minute.
Correct answer: B
Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.
3. When implementing a new policy on the unit, what process should a nurse manager follow?
- A. The nurse manager should involve staff members in the decision-making process, gather input, and communicate the reasons for the policy change to ensure buy-in from the team.
- B. The nurse manager should implement the policy change immediately and monitor staff compliance to ensure that the new policy is being followed.
- C. The nurse manager should delegate the implementation of the policy change to a staff member and provide support as needed to ensure that the change is successful.
- D. The nurse manager should communicate the policy change to staff members, provide training as needed, and monitor the implementation process to ensure that the change is effective.
Correct answer: A
Rationale: When introducing a new policy on the unit, it is essential for the nurse manager to involve staff members in the decision-making process. This approach helps in gathering input and insights from the team, fostering a sense of ownership and commitment. By communicating the reasons behind the policy change, the nurse manager ensures transparency and promotes understanding among the staff, leading to buy-in and acceptance of the new policy. Choice B is incorrect because implementing a policy change without involving staff and explaining the rationale may lead to resistance or lack of understanding. Choice C is not ideal as delegation without active involvement and communication with the team may result in misunderstandings or incomplete implementation. Choice D lacks the crucial step of involving staff in the decision-making process, which is important for successful policy implementation and team engagement.
4. When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?
- A. Fiber
- B. Folate
- C. Ascorbic acid
- D. Vitamin B12
Correct answer: D
Rationale: Vitamin B12 is an essential nutrient predominantly found in animal products. Individuals following a vegan diet, which excludes animal products, are at a higher risk of vitamin B12 deficiency. Encouraging the client to include a vitamin B12 supplement in their dietary plan is crucial to prevent deficiency-related health issues. Choices A, B, and C are not specific to addressing the deficiency that vegan diets may cause. Fiber, folate, and ascorbic acid are important but do not directly address the risk of vitamin B12 deficiency in vegan diets.
5. A community health nurse is planning a program to address the rising rates of obesity in the community. Which intervention should the nurse prioritize?
- A. organizing community exercise programs
- B. distributing educational materials on healthy eating
- C. partnering with local grocery stores to provide discounts on healthy foods
- D. conducting health screenings for early detection of obesity-related conditions
Correct answer: A
Rationale: The correct answer is A: organizing community exercise programs. Physical activity plays a crucial role in weight management and reducing obesity rates. While educating about healthy eating (choice B) is important, focusing on exercise programs can have a more direct impact on addressing obesity. Partnering with local grocery stores for discounts on healthy foods (choice C) is beneficial but may not address the root cause of obesity. Conducting health screenings (choice D) is more reactive than proactive in addressing rising obesity rates.