HESI RN
Community Health HESI Questions
Question 1 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 2 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.
Question 3 of 5
A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?
Correct Answer: D
Rationale: In this scenario, option D, an International Normalized Ratio (INR) of 2.5, indicates that warfarin therapy is effective for a client with atrial fibrillation. The INR measures the effectiveness of warfarin in thinning the blood to prevent clot formation. An INR within the therapeutic range of 2.0 to 3.0 (or sometimes 2.5 to 3.5) is considered effective in preventing clotting events for patients on warfarin therapy. Option A, an INR of 1.0, is too low and indicates inadequate anticoagulation, putting the client at risk for clotting. Option B, a Prothrombin Time (PT) of 12 seconds, is a measurement of how long it takes for blood to clot and is not specific to monitoring warfarin therapy. Option C, a Partial Thromboplastin Time (PTT) of 60 seconds, is also not used to monitor warfarin therapy but rather to assess other clotting factors. In an educational context, understanding lab values and their significance in monitoring anticoagulant therapy is crucial for nurses in community health settings. Monitoring INR levels helps prevent complications such as stroke or bleeding in patients on warfarin therapy, making it essential for nurses to interpret and act upon these results accurately.
Question 4 of 5
The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: Heart rate of 90 beats per minute. An elevated heart rate in a client with pneumonia indicates potential complications such as sepsis or inadequate oxygenation. This finding requires immediate intervention as it could signify a worsening condition requiring urgent medical attention to prevent further deterioration. Option A: A temperature of 99°F is within normal limits and may not require immediate intervention as it is not indicative of a critical condition in this context. Option B: A respiratory rate of 20 breaths per minute is within the normal range and may not be an immediate cause for concern in a client with pneumonia. Option D: Fatigue is a common symptom of pneumonia but does not indicate an urgent need for intervention compared to a high heart rate. Educationally, understanding the significance of vital sign abnormalities in pneumonia assessment is crucial for nurses to identify and prioritize interventions effectively to ensure positive patient outcomes.
Question 5 of 5
During a home visit, the nurse observes that a client with limited mobility has difficulty accessing the bathroom. What should the nurse do first?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) suggest the client installs a bedside commode. The rationale behind this is that suggesting a bedside commode directly addresses the immediate need of the client with limited mobility. A bedside commode provides a practical solution to the client's difficulty in accessing the bathroom independently, promoting safety and preserving their dignity. Option B) assisting the client in modifying the home environment could be a valid intervention, but it may not address the immediate need as effectively as providing a bedside commode. Option C) referring the client to an occupational therapist is important for long-term planning and comprehensive care but does not address the client's immediate issue with bathroom accessibility. Option D) educating the client on mobility aids is also valuable but does not directly address the client's current challenge accessing the bathroom. From an educational perspective, it is crucial for nurses to prioritize immediate needs during home visits to ensure the safety and well-being of clients. Understanding the hierarchy of needs and implementing timely interventions is fundamental in community health nursing practice. By choosing the most appropriate and effective solution for the client's immediate concern, nurses can enhance quality of care and promote client independence and comfort in their home environment.