HESI RN
HESI Community Health Questions
Question 1 of 5
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is to administer the dose of verapamil (Calan) as prescribed (Option A). Verapamil is a calcium channel blocker commonly used to treat atrial flutter by slowing down the heart rate and controlling heart rhythm. The client's heart rate of 92 is within a normal range, and the blood pressure of 110/76 is also acceptable for administering this medication. Option B, holding the medication, would not be appropriate in this case as the client's vital signs are stable and within the normal range for administering verapamil. Option C, calling the healthcare provider, is not necessary at this time since the vital signs are appropriate for medication administration and there are no contraindications present. Option D, repeating the vital signs in 30 minutes, is not required as the initial vital signs are within an acceptable range for administering verapamil. It is important for the nurse to understand the pharmacological effects of verapamil, the client's condition of atrial flutter, and how to monitor for potential side effects or adverse reactions post-administration. This question highlights the importance of assessing vital signs before administering medications and understanding the implications of those vital signs on medication administration in community health settings.
Question 2 of 5
The wife of an older adult man who has had diabetes mellitus for the past 10 years reports to the home health nurse that her husband fell yesterday while taking his daily walk in the neighborhood. He has a bruised hand and a small abrasion on his left knee. The nurse assesses that his neurologic vital signs are stable. To reduce risk for future falls, which assessment is most important for the nurse to obtain?
Correct Answer: B
Rationale: In this scenario, the most important assessment for the nurse to obtain to reduce the risk of future falls for the older adult man with diabetes mellitus is the degree of paresthesia in his feet (Option B). Paresthesia, which refers to abnormal sensations like tingling or numbness, is common in individuals with diabetes and can increase the risk of falls due to decreased sensation and proprioception in the feet. Assessing the current blood sugar level (Option A) is important in managing diabetes, but in this case, the focus is on preventing falls specifically related to neuropathy. Checking the wound healing of the knee abrasion (Option C) is important for overall care but does not directly address fall prevention. A1c glycosylated hemoglobin (Option D) provides information about long-term blood sugar control but does not address the immediate risk of falls due to neuropathy. Educationally, this question highlights the importance of assessing for paresthesia in diabetic patients to prevent falls, a common complication in this population. It emphasizes the need for nurses to prioritize assessments based on the patient's specific condition and risk factors to provide targeted and effective care.
Question 3 of 5
The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C) contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year. This intervention is the most direct and effective way to ensure that students receive the necessary immunizations in a timely manner. By directly contacting parents, the school nurse can communicate the importance of completing the vaccine series and provide clear instructions for compliance. Option A is incorrect because simply noting in student records does not actively ensure that the second dose is administered. Option B is less effective as sending notices home on the first day of class may lead to delays in compliance. Option D is also incorrect as speaking at a PTA meeting may not reach all parents and may not result in immediate action. In an educational context, this question highlights the role of the school nurse in promoting and maintaining the health of students through effective communication and proactive measures to ensure compliance with immunization requirements. It emphasizes the importance of timely vaccination to prevent the spread of vaccine-preventable diseases in a school setting.
Question 4 of 5
During a home visit, a nurse observes an older client who is attempting to ambulate to the bathroom and notes that the client is unsteady and holds on to the furniture while refusing any assistance. Which action should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to implement is to determine home navigational safety hazards (Option A). This is crucial because the nurse has observed the client being unsteady while ambulating, which indicates potential safety risks within the home environment. By assessing and identifying these hazards, the nurse can create a safer space for the client to move around independently and reduce the risk of falls or accidents. Option B, maintaining the client's privacy while in the bathroom, is not the most appropriate action in this situation as the primary concern is the client's safety while ambulating. While privacy is important, it is secondary to ensuring the client's physical safety. Option C, recommending that the client obtain a walker, and Option D, encouraging the client to obtain a medical alert device, are also not the most immediate actions to take. While both of these interventions may be beneficial for the client in the long run, addressing the home safety hazards is the most critical step to prevent immediate harm or injury to the client. In the context of community health nursing, it is essential for nurses to prioritize client safety and well-being during home visits. By addressing environmental safety concerns, nurses can empower clients to maintain their independence and quality of life while minimizing the risk of accidents or injuries in their home environment.
Question 5 of 5
While screening all children in the third grade for head lice, the school nurse observes that one girl has a brownish thickening on her neck. Which action should the nurse take in response to this finding?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is to advise the child's parents to obtain a medical evaluation of the brownish thickening on the child's neck (Option C). This is the most appropriate response as the nurse has identified a potentially concerning physical finding that requires further assessment by a healthcare provider. By recommending a medical evaluation, the nurse ensures that the child receives timely and appropriate care for any underlying condition. Option A is incorrect because reviewing the child's medical folder for a list of allergies is not relevant to addressing the brownish thickening on the neck. Option B, instructing the child's parents to begin treatment without a proper diagnosis, is inappropriate as it may not address the root cause of the issue and could potentially lead to incorrect or ineffective treatment. In an educational context, this question highlights the importance of thorough assessment and appropriate referral in community health nursing. It emphasizes the role of the nurse in recognizing abnormal findings, advocating for the well-being of the child, and collaborating with other healthcare professionals to ensure comprehensive care. By understanding the rationale behind the correct response, nursing students can develop critical thinking skills and clinical judgment necessary for effective practice in community health settings.