HESI RN
Community Health HESI Quizlet
1. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water-seal chamber.
- B. No fluctuation (tidaling) in the water-seal chamber.
- C. Intermittent bubbling in the suction control chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct answer: D
Rationale: The drainage of clear, pale yellow fluid from the chest tube is an indication of proper chest tube functioning. Clear, pale yellow fluid signifies normal drainage from the pleural space without any signs of infection or complications. Choices A, B, and C are incorrect because continuous bubbling in the water-seal chamber, no fluctuation in the water-seal chamber, and intermittent bubbling in the suction control chamber are all indications of potential issues or malfunctioning of the chest tube system, which would require further assessment and intervention.
2. A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct answer: A
Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.
3. One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the healthcare provider take immediately?
- A. Give the medication as prescribed and monitor for efficacy.
- B. Encourage the client to breastfeed rather than bottle-feed.
- C. Have the client empty her bladder and massage the fundus.
- D. Call the healthcare provider to question the prescription.
Correct answer: D
Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.
4. The client with chronic renal failure is receiving hemodialysis. Which of the following laboratory values should the nurse monitor closely?
- A. Hemoglobin level.
- B. Blood urea nitrogen (BUN) level.
- C. Serum potassium level.
- D. Creatinine level.
Correct answer: C
Rationale: The serum potassium level should be monitored closely in clients undergoing hemodialysis due to the risk of hyperkalemia. Hemodialysis is used to remove waste products and excess electrolytes like potassium from the blood. Monitoring potassium levels is crucial because an imbalance can lead to serious cardiac complications, making it the priority value to monitor in this scenario. Monitoring hemoglobin levels (choice A) is important for anemia assessment in chronic renal failure but is not directly related to hemodialysis. Blood urea nitrogen (BUN) levels (choice B) and creatinine levels (choice D) are commonly monitored in renal function tests but are not the top priority for monitoring in a client undergoing hemodialysis.
5. What is another name for the breast?
- A. Sebaceous glands
- B. Racemose glands
- C. Mammary glands
- D. Axillary glands
Correct answer: C
Rationale: The correct answer is C: Mammary glands. The mammary glands are the specific glands in the breast responsible for producing milk. Sebaceous glands (choice A) are oil-producing glands in the skin, racemose glands (choice B) are not a recognized term, and axillary glands (choice D) refer to glands found in the armpit region, not the breast.