the nurse is preparing to administer an intravenous iv medication to a client which action should the nurse take first
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Nursing Elites

HESI RN

Community Health HESI 2023

1. The healthcare provider is preparing to administer an intravenous (IV) medication to a client. Which action should the healthcare provider take first?

Correct answer: B

Rationale: Checking the client's allergy status is the priority before administering any medication, especially intravenously. This step helps identify any potential allergic reactions and prevents harm to the client. Verifying the client's identity using two identifiers is important but not the first step in medication administration. Preparing the medication for administration and administering the medication at the prescribed rate come after ensuring the client's safety by checking for allergies.

2. Following a blizzard that resulted in millions of dollars of damage, the community health nurse is planning to seek financial assistance for families affected by the disaster. Which contact is most important for the nurse to make?

Correct answer: B

Rationale: The correct answer is B, the Federal Emergency Management Agency (FEMA). FEMA is the primary agency responsible for providing financial assistance and support during disasters. While the governor's disaster relief program may also offer help, FEMA has more extensive resources and expertise in disaster response. Local churches providing shelter and seeking volunteer contributions from the community are valuable resources but may not offer the comprehensive financial assistance that FEMA can provide in such situations.

3. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

Correct answer: A

Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.

4. When developing a presentation on injury prevention for high school students in a health education class, which topic is most important for the nurse to include?

Correct answer: C

Rationale: The correct answer is C: Seat belt safety. This topic is crucial as it can significantly reduce the risk of injury or death in car accidents, which is a common cause of severe injuries among high school students. While sports-related injuries, substance abuse, and pregnancy prevention are important topics, seat belt safety directly addresses a preventable cause of injuries that can have immediate life-saving effects.

5. The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which finding supports this diagnosis?

Correct answer: D

Rationale: The correct answer is D: Redness and warmth in the affected leg. These are classic signs of deep vein thrombosis (DVT) and support the diagnosis. Choice A, Positive Homan's sign, is an outdated and unreliable test for DVT, so it is not the best choice. Choice B, Unilateral leg swelling, can be seen in DVT but is less specific compared to redness and warmth. Choice C, Bilateral calf pain, is not a typical finding in DVT, as the pain in DVT is usually unilateral.

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