HESI RN
HESI Community Health
1. After coronary artery bypass graft surgery, a male client is admitted to the coronary care unit. Which nursing diagnosis is of the highest priority?
- A. Ineffective breathing pattern.
- B. Impaired gas exchange.
- C. Acute pain.
- D. Risk for infection.
Correct answer: B
Rationale: Impaired gas exchange is the highest priority nursing diagnosis because it directly impacts the client's oxygenation. Following coronary artery bypass graft surgery, ensuring adequate oxygen exchange is crucial for the client's recovery. Ineffective breathing pattern, although important, may not be as critical as impaired gas exchange in the immediate postoperative period. Acute pain, while significant, can be managed effectively with appropriate interventions and is not as emergent as addressing impaired gas exchange. Risk for infection is also a valid concern post-surgery, but ensuring optimal gas exchange takes precedence to prevent complications associated with inadequate oxygenation.
2. The healthcare professional is developing a health education program for adolescents on the dangers of smoking. Which strategy is most likely to be effective?
- A. showing graphic images of the effects of smoking
- B. inviting former smokers to share their experiences
- C. providing statistical data on smoking-related illnesses
- D. distributing pamphlets on smoking cessation resources
Correct answer: B
Rationale: Inviting former smokers to share their experiences is the most effective strategy because personal stories can have a powerful impact on adolescents and motivate them to avoid smoking. This approach makes the consequences of smoking more relatable and real, potentially influencing behavior change. Showing graphic images may be too harsh and could lead to desensitization or avoidance of the issue. Providing statistical data may not resonate as strongly with adolescents as personal stories. Distributing pamphlets, while informative, may not have the same emotional impact as hearing real-life experiences.
3. The healthcare provider is conducting a health assessment for a family in a rural area. Which intervention should the healthcare provider prioritize to address the family's health needs?
- A. Providing information on local healthcare resources
- B. Teaching the family about proper nutrition
- C. Assisting the family in scheduling medical appointments
- D. Connecting the family with transportation services
Correct answer: A
Rationale: In rural areas, access to healthcare may be limited. Providing information on local healthcare resources is essential to ensure the family can access necessary services. While proper nutrition (choice B) and medical appointments (choice C) are important, having access to healthcare resources is fundamental. Transportation services (choice D) may be helpful but addressing the availability of healthcare resources should be the priority.
4. A client with a history of diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which finding requires immediate intervention?
- A. Blood glucose of 200 mg/dL.
- B. Serum bicarbonate of 20 mEq/L.
- C. Blood pressure of 140/90 mm Hg.
- D. Urine output of 50 mL in 4 hours.
Correct answer: D
Rationale: In a client with diabetic ketoacidosis (DKA), urine output of 50 mL in 4 hours indicates oliguria, which is a concerning sign of decreased renal perfusion and potential renal failure. This finding requires immediate intervention to prevent further deterioration of kidney function.\n\nChoice A (Blood glucose of 200 mg/dL) is elevated but not the most urgent concern in this scenario. Choice B (Serum bicarbonate of 20 mEq/L) reflects metabolic acidosis, which is expected in DKA but does not require immediate intervention. Choice C (Blood pressure of 140/90 mm Hg) is slightly elevated but not acutely concerning in the context of DKA.
5. The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
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