HESI Community Health

Correct Answer: C

Rationale: The correct answer is C. When documenting assessment data in the narrative nursing notes, it is essential to include objective findings that are specific, clear, and descriptive. 'S1 murmur auscultated in supine position' provides a precise and objective assessment finding that can aid in accurately documenting the client's condition. Choices A, B, and D are more subjective statements that lack the specificity and clarity required for detailed documentation. 'Client appears anxious' and 'Client is resting quietly' are subjective observations, while 'Client's skin is warm and dry' is an objective finding but may not be as significant or relevant for comprehensive documentation as the auscultated murmur.

Correct Answer: B

Rationale: Placing the client in a high Fowler's position helps improve breathing and oxygenation in clients with severe dyspnea.

Correct Answer: D

Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.

Correct Answer: C

Rationale: A serum creatinine level of 1.0 mg/dL is within the normal range, but weight gain of 2 pounds in 24 hours indicates fluid retention and requires immediate intervention.

Correct Answer: C

Rationale: A medical evaluation is necessary to properly diagnose and treat the condition observed.