HESI Community Health

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While assessing a client receiving a blood transfusion, which finding requires immediate intervention?

  • A. Temperature of 100.4°F (38°C).
  • B. Blood pressure of 110/70 mm Hg.
  • C. Heart rate of 90 beats per minute.
  • D. Complaints of feeling cold.
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.

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A public health nurse is planning a smoking cessation program for a local community. Which component is most important to include in the program?

  • A. information on the health risks of smoking
  • B. strategies for coping with withdrawal symptoms
  • C. testimonials from former smokers
  • D. distribution of nicotine replacement therapy
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The nurse is developing a workshop on cancer prevention for a group of adults at a wellness bar. Which recommendation should the nurse include in the workshop?

  • A. know the 4 warning signs of cancer
  • B. maintain a healthy weight and exercise regularly
  • C. refrain from alcohol
  • D. obtain at least 6 to 10 hours of sleep per night
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?

  • A. Continue the heparin infusion as prescribed.
  • B. Decrease the heparin infusion rate.
  • C. Increase the heparin infusion rate.
  • D. Stop the heparin infusion and notify the healthcare provider.
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.

A client with a history of heart failure is admitted with severe dyspnea. Which intervention should the nurse implement first?

  • A. Administer oxygen at 2 liters per minute via nasal cannula.
  • B. Place the client in a high Fowler's position.
  • C. Obtain a 12-lead electrocardiogram (ECG).
  • D. Administer intravenous furosemide (Lasix).
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The healthcare provider is assessing a client with a suspected stroke. Which finding requires immediate intervention?

  • A. Blood pressure of 160/90 mm Hg.
  • B. Blood glucose level of 180 mg/dL.
  • C. Difficulty speaking.
  • D. Temperature of 99.8°F (37.7°C).
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.

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