HESI RN
HESI Community Health Questions
Question 1 of 5
The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?
Correct Answer: C
Rationale: Difficulty speaking is a classic symptom of stroke, suggesting a potential blockage of blood flow to the brain. Prompt intervention is crucial to minimize brain damage. Elevated blood pressure (Choice A) may need management but is not the most urgent concern in this scenario. A blood glucose level of 180 mg/dL (Choice B) is slightly elevated but does not require immediate intervention for a suspected stroke. A temperature of 99.8°F (37.7°C) (Choice D) is within normal range and not a critical finding in this context.
Question 2 of 5
During a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?
Correct Answer: A
Rationale: The 45-year-old father who smokes and has high cholesterol should be prioritized for further evaluation and intervention. He has multiple risk factors for cardiovascular disease, including smoking and high cholesterol, which significantly increase his risk. Addressing these modifiable risk factors is crucial in preventing cardiovascular events. The daughter (Choice B) and mother (Choice C) also have risk factors, but the father's combination of smoking and high cholesterol places him at higher immediate risk, demanding priority intervention. The 12-year-old son (Choice D) with a normal weight and an active lifestyle has a lower risk profile and does not require immediate intervention compared to the father.
Question 3 of 5
A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?
Correct Answer: D
Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.
Question 4 of 5
While assessing a client receiving a blood transfusion, which finding requires immediate intervention?
Correct Answer: C
Rationale: A heart rate of 90 beats per minute requires immediate intervention when assessing a client receiving a blood transfusion. This finding can indicate a potential transfusion reaction, such as a hemolytic reaction or fluid overload, which requires prompt evaluation and management to prevent serious complications. While a temperature of 100.4°F (38°C) may indicate a mild fever, it is not typically an immediate concern during a blood transfusion. A blood pressure of 110/70 mm Hg is within the normal range, and complaints of feeling cold can be addressed but do not indicate an urgent need for intervention compared to the critical nature of a potential transfusion reaction indicated by an elevated heart rate.
Question 5 of 5
The healthcare provider is caring for a client with a chest tube. Which intervention is most important to include in the plan of care?
Correct Answer: D
Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.