HESI RN CONCEPT BASED ASSESSMENT LEVEL 1<\/p>\n\n\n\n
A nurse is reviewing a client’s new prescriptions that were just
documented in the client’s medical record by the provider. Which of the
following abbreviations should the nurse clarify with the provider? –
ANSWER- Enoxaparin 40 mg SQ QD
Rationale: (The nurse should clarify this prescription with the
provider. The abbreviations “SQ” and “QD” are considered error\u0002prone and should not be used in documentation. The nurse should
clarify that the provider intends the prescription to be administered
subcutaneously once daily. “Subcutaneous” or “subcut” should be
used instead of “SQ” and “daily” should be used instead of “QD.”)
A community health nurse is participating in a task force initiative to
reduce the incidence of disease from injection drug use among the city’s
homeless population. Which of the following plans should the nurse
recommend as part of tertiary prevention? – ANSWER- Start a needle\u0002exchange program.
Rationale: (Initiating a program for needle exchange and treating
clients who are homeless for any diseases they may have already
acquired are examples of tertiary prevention.)<\/p>\n\n\n\n
A nurse is performing a focused assessment on a client who has chronic
pain due to fibromyalgia. Which of the following questions should the
nurse ask to access the quality of the client’s pain? – ANSWER- “Can
you describe what your pain feels like?”
Rationale: (The nurse should ask the client to describe her pain
when assessing pain quality. The quality of a client’s pain can be
expressed using adjectives such as “piercing,” “stabbing,” and
“aching.”)
A nurse is planning to use an interpreter to assist her when interviewing
a client who does not speak the same language as the nurse. Which of
the following actions should the nurse plan to take? – ANSWER- Ensure
the client and the interpreter are compatible.
Rationale: (The nurse should ensure that the client is comfortable
with the interpreter. The nurse should consider the client’s age,
gender, and culture when using an interpreter.)
A community health nurse is planning interventions to promote Healthy
People 2020 initiatives in the community. Which of the following
actions should the nurse plan to take first? – ANSWER- Determine the
level of health equity groups among groups in the community.
Rationale: (Health equity among all groups in the community is a
Healthy People 2020 initiative. Using the nursing process, the first
action the nurse should take is to assess the needs of the community.
By identifying disparities in community health, the nurse can
develop interventions targeted at the community’s specific needs.)
A nurse is planning care for a client who has bacterial meningitis caused
by Haemophilus influenza. Which of the following infection control<\/p>\n\n\n\n
interventions should the nurse include in the plan? – ANSWER- Place a
mask on the client during transport out of the room.
Rationale: (The nurse should implement droplet precautions and
standard precautions when caring for a client who has bacterial
meningitis caused by H. influenza. The nurse should avoid
transporting the client out of the room, if possible. However, if
transport is necessary, then placing a mask on the client is an
effective infection control intervention.)
A nurse is planning care for a newly-admitted school-age child who has
rubeola. Which of the following isolation precautions should the nurse
plan to initiate? – ANSWER- Airborne
Rationale: (The nurse should initiate airborne precautions for a
client who has varicella, measles (rubeola), or pulmonary
tuberculosis. Airborne precautions include a private room with
negative pressure airflow, with 6 to 12 air exchanges\/hr via a high\u0002efficiency particulate air (HEPA) filtration system.)
A nurse is administering ophthalmic solution to a client who has
bacterial conjunctivitis. Which of the following actions should the nurse
take? – ANSWER- Have the client lie supine.
Rationale: (This is a comfortable position for the client, and it
makes it easy for the nurse to access the eye. It also reduces the risk
of the medication escaping through the tear duct.)
A nurse is teaching sleep hygiene to a client who has insomnia. Which
of the following statements should the nurse make? – ANSWER-
“Exercise in the morning after arising.”<\/p>\n\n\n\n
Rationale: (Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The
nurse should recommend that the client avoid exercising within 2 hr
of bedtime to limit stimulation and enhance sleep.)
A nurse is preparing to administer enoxaparin subcutaneously to a client
who is postoperative following orthopedic surgery. The nurse should
plan to administer this medication in which of the following locations?
(You will find hot spots to select in the artwork below. Select only the
hot spot that corresponds to your answer.) – ANSWER- ~A is incorrect.
The outer posterior aspect of the upper arms is a site commonly used for
subcutaneous injections. However, it is not recommended for
administration of low molecular weight heparins such as enoxaparin.
The nurse should select another subcutaneous injection site to promote
absorption of the enoxaparin.
~B is correct. The nurse should administer low molecular weight
heparins, such as enoxaparin, into the anterolateral aspect of the client’s
abdomen to promote absorption of the medication. Other recommended
subcutaneous sites for this medication include the posterolateral aspect
of the client’s abdomen, the buttocks, and the upper thighs.
~C is incorrect. The abdomen is a site commonly used for subcutaneous
injections. However, it is not recommended to administer medications
within 5 cm (2 in) of the umbilicus. The nurse should select another site
to administer the enoxaparin.
A nurse is providing teaching about nutrition management to the parent
of an 18-month-old toddler who has phenylketonuria. Which of the
following foods should the nurse recommend? – ANSWER- Baked
potato<\/p>\n\n\n\n