Community Health HESI 2023 Quizlet

Correct Answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3�F (37.9�C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

Correct Answer: D

Rationale: In this scenario, the correct action is to apply a water-soluble lubricant to the lips, oral mucosa, and nares. This helps in keeping the mucous membranes moist, which is essential for a client with a dry mouth due to the nasogastric tube and oxygen therapy. Choice A, applying a petroleum-based lubricant to the lips, is not suitable as it may not be safe for internal use. Choice B, giving sips of water, is contraindicated as the client has a nasogastric tube in place for suction. Choice C, providing ice chips, is also not recommended as the client needs proper lubrication to address dryness, not cold stimulation.

Correct Answer: C

Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.

Correct Answer: C

Rationale: Opening the client's airway immediately is the priority in this scenario. Ensuring the airway is clear takes precedence over other actions as it is crucial for the client's breathing and oxygenation. Logrolling the client to assess for back injuries may worsen the condition if there are spinal injuries, so this should not be done as the first step. Performing a complete neurological assessment is important but not the immediate priority over ensuring the airway is clear. Placing the nurse's hands around the client's neck to stabilize is incorrect and could potentially harm the client, as neck stabilization should only be done if there is a suspected neck injury, which is not indicated in this case.

Correct Answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.