HESI RN
Community Health HESI Questions
Question 1 of 5
During a 2 wk postoperative follow-up home visit, a female client who had gastric bypass surgery exhibits bad tenderness, shoulder pain, & describes feelings of malaise. Her vital signs are: T 101.8, BP 100/50, HR 104, and RR 18. Which action should the RN take?
Correct Answer: A
Rationale: In this scenario, the correct action for the RN to take is option A: have the client transported via ambulance to the hospital. This choice is based on the client's presentation of symptoms indicating a potential serious postoperative complication, such as an anastomotic leak after gastric bypass surgery. The presence of tenderness, shoulder pain, malaise, and elevated temperature along with hypotension, tachycardia, and tachypnea are concerning signs that warrant immediate medical attention. Option B, to recheck vital signs in 30 minutes, is not appropriate in this case as the client's symptoms suggest a potentially critical condition that requires prompt intervention. Option C, instructing the client to drive to the hospital, is unsafe due to the client's condition and the need for urgent medical evaluation. Option D, determining the client's current symptoms, is unnecessary as the client's presentation already indicates the need for immediate medical assessment and intervention. In an educational context, this scenario highlights the importance of recognizing and responding to postoperative complications promptly in community health nursing. It emphasizes the critical thinking skills needed to prioritize actions based on assessment findings and the significance of timely intervention in ensuring patient safety and optimal outcomes. Nurses must be prepared to act decisively in emergent situations to provide appropriate care and support to patients in the community setting.
Question 2 of 5
During a follow-up visit, a client with hypertension reports that they often forget to take their medication. What should the nurse do first?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) explore the reasons for the client's forgetfulness. This option is the most appropriate first step because it allows the nurse to assess the underlying causes of the client's non-adherence to medication. By exploring the reasons behind the forgetfulness, the nurse can uncover potential barriers such as cognitive issues, financial constraints, lack of understanding, or side effects that may be contributing to the client's behavior. Option A) educate the client on the importance of medication adherence may be necessary, but it should come after understanding the client's reasons for forgetfulness. Simply providing education without addressing the root cause may not effectively improve adherence. Option C) providing the client with a pill organizer assumes that forgetfulness is the only issue at play and may not address the underlying reasons for non-adherence. Option D) adjusting the client's medication schedule should also come after exploring the reasons for forgetfulness to ensure that any changes made are appropriate and effective. In the context of community health nursing, it is essential to take a holistic and patient-centered approach to address medication adherence issues. By first exploring the reasons behind the forgetfulness, nurses can tailor interventions to best support the client in managing their hypertension effectively.
Question 3 of 5
During a home visit, the nurse observes that an elderly client has a cluttered living environment and poor lighting. What should the nurse do first?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) assess the client's risk for falls. This is the most appropriate initial action for the nurse to take. By assessing the client's risk for falls, the nurse can address immediate safety concerns and prioritize interventions to prevent potential accidents or injuries. Option A) suggesting the client hires a cleaning service may address the cluttered environment but does not directly address the safety issue of falls. Option B) assisting the client in organizing the living space also focuses on the clutter but does not address the immediate risk of falls. Option D) providing the client with information on home safety is important but should come after assessing the specific risk factors present in the client's environment. Educationally, this question highlights the importance of prioritizing interventions based on the immediate needs of the client. Assessing risk factors is fundamental in developing a holistic and individualized care plan, especially in community health nursing where environmental factors play a significant role in overall health and safety. It is crucial for nurses to identify and address safety concerns proactively to promote the well-being of their clients.
Question 4 of 5
During a follow-up visit, a client with diabetes reports difficulty maintaining a healthy diet. What should the nurse do first?
Correct Answer: B
Rationale: In this scenario, the correct response is option B: explore the client's dietary habits and challenges. This option is the most appropriate initial action because it allows the nurse to gather crucial information about the client's specific struggles with maintaining a healthy diet. By understanding the client's barriers, preferences, and lifestyle factors influencing their dietary choices, the nurse can tailor interventions effectively. Option A, providing the client with meal planning resources, may be premature without understanding the client's individual needs and obstacles. Option C, referring the client to a nutritionist, is not the first step as the nurse should assess the situation before involving additional healthcare professionals. Option D, educating the client on the importance of a healthy diet, is not as effective as exploring the client's challenges first, as education alone may not address the underlying issues hindering the client's dietary adherence. In the educational context, this question highlights the importance of a client-centered approach in community health nursing. By prioritizing a thorough assessment of the client's needs and challenges, nurses can develop personalized and effective interventions to support clients in achieving optimal health outcomes. This approach aligns with the principles of holistic care and individualized treatment in community health nursing practice.
Question 5 of 5
The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Hypokalemia. When a client has a nasogastric tube to continuous suction, there is a risk of electrolyte imbalances due to the continuous removal of gastric contents, which can lead to potassium depletion. Potassium is essential for proper nerve and muscle function, including the heart. Monitoring for hypokalemia is crucial to prevent cardiac dysrhythmias and other serious complications in the client. Option A) Hypercalcemia is incorrect because continuous suction would not typically lead to elevated calcium levels. Option C) Hyponatremia is unlikely to occur in this situation as sodium levels are not directly impacted by nasogastric tube suction. Option D) Hypomagnesemia is also incorrect as magnesium levels are not typically affected by the continuous suction of gastric contents. Educationally, understanding the implications of nasogastric tube suction on electrolyte balance is essential for nurses working in community health settings. It highlights the importance of close monitoring and early intervention to prevent potentially life-threatening complications in clients with nasogastric tubes.