HESI RN
Community Health HESI
1. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?
- A. I am very anxious about the surgery.
- B. I drank a glass of juice after midnight.
- C. I have an allergy to latex.
- D. I had nausea after my last surgery.
Correct answer: B
Rationale: The correct answer is B. The client's statement of drinking juice after midnight should be reported to the healthcare provider. Consuming liquids after midnight can increase the risk of aspiration during surgery under general anesthesia. Choices A, C, and D are not as critical to report for the client's safety during the surgical procedure. Anxiety about surgery, latex allergy, and postoperative nausea, although important for overall care, do not pose immediate risks during the surgical preparation as the intake of fluids does.
2. Which of the following is not a complication of menopause?
- A. Fractures
- B. Alzheimer's disease
- C. Congestive heart failure
- D. Painful intercourse
Correct answer: C
Rationale: Congestive heart failure is not typically associated with menopause. Menopause is linked to an increased risk of fractures due to bone density loss, a higher risk of Alzheimer's disease due to hormonal changes affecting the brain, and painful intercourse due to vaginal dryness and decreased lubrication. While cardiovascular health can be affected by menopause, congestive heart failure is not a direct complication of menopause.
3. What is the composition of the cellular membrane?
- A. A bilayer of phospholipid molecules
- B. A single layer of phospholipid molecules
- C. Proteins that act as transport highways
- D. Carbohydrates
Correct answer: A
Rationale: The cellular membrane is primarily composed of a phospholipid bilayer, which consists of two layers of phospholipid molecules. These molecules have a hydrophilic (water-attracting) head and hydrophobic (water-repelling) tail, creating a barrier that separates the internal cellular environment from the external surroundings. While proteins are embedded within this bilayer and act as transport channels, receptors, and structural support, carbohydrates are found on the outer surface of the membrane for cell recognition and signaling purposes. Therefore, the correct answer is a bilayer of phospholipid molecules.
4. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
- A. Document the client’s temperature fluctuations
- B. Assess for flushed, warm skin consistently
- C. Measure temperature at regular intervals
- D. Use different sites for temperature measurement
Correct answer: C
Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.
5. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?
- A. Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely
- B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
- C. Let me contact your surgeon and find out if Heparin IV therapy can be administered to you at home
- D. Why are you so anxious to leave the hospital when you know you are not well enough yet?
Correct answer: A
Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.