while assessing an rh positive newborn whose mother is rh negative the nurse recognizes the risk for hyperbilirubinemia which of the following should
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Community Health HESI Questions

1. While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

Correct answer: C

Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.

2. The nurse is caring for an acutely ill 10-year-old client. Which of the following assessments would require the nurse's immediate attention?

Correct answer: D

Rationale: The correct answer is D, slow, irregular respirations. In an acutely ill child, this assessment can indicate impending respiratory failure or neurological compromise, necessitating immediate intervention. Rapid bounding pulse (choice A) may indicate tachycardia but is not as immediately concerning as compromised respirations. A temperature of 38.5 degrees Celsius (choice B) is elevated but may not be the most urgent concern unless accompanied by other symptoms. Profuse diaphoresis (choice C) can indicate increased sympathetic activity but is not as critical as respiratory compromise.

3. To prevent keratitis in an unconscious client, where should the nurse apply moisturizing ointment?

Correct answer: B

Rationale: The correct answer is B: Eyes. Applying moisturizing ointment to the eyes helps prevent keratitis, a condition that can occur due to inadequate blinking in unconscious clients, leading to corneal dryness and potential damage. Choices A, C, and D are incorrect as moisturizing ointment should not be applied to finger and toenail quicks, perianal area, or external ear canals to prevent keratitis.

4. When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?

Correct answer: A

Rationale: The correct answer is A: 'Impaired physical mobility related to muscle rigidity and weakness.' For a client with Parkinson's disease, impaired physical mobility is a priority nursing diagnosis because of the characteristic motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Addressing impaired physical mobility is crucial to enhance the client's quality of life. Choices B, C, and D are not the priority nursing diagnoses for a client with Parkinson's disease. Ineffective coping (Choice B) and fear of seizures (Choice D) may be concerns but are not the priority. Ineffective breathing pattern (Choice C) is not typically associated with Parkinson's disease.

5. A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?

Correct answer: D

Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.

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