HESI LPN
Adult Health 1 Exam 1
1. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?
- A. Encourage mobilization and ambulation
- B. Encourage energy conservation with complete bed rest
- C. Provide humidified oxygen via nasal cannula
- D. Restrict oral (PO) and intravenous fluids
Correct answer: A
Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.
2. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important assessment before administering this medication?
- A. Check blood pressure.
- B. Assess heart rate.
- C. Monitor respiratory rate.
- D. Measure oxygen saturation.
Correct answer: B
Rationale: The correct answer is to assess the heart rate. Before administering digoxin, it is essential to evaluate the heart rate as digoxin can cause bradycardia. While checking blood pressure, monitoring respiratory rate, and measuring oxygen saturation are important assessments in the care of a client with chronic heart failure, assessing the heart rate is particularly critical due to the medication's potential impact on heart rhythm.
3. A client with hypothyroidism is taking levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?
- A. Weight gain
- B. Bradycardia
- C. Nervousness and tremors
- D. Fatigue
Correct answer: C
Rationale: The correct answer is C: Nervousness and tremors. These symptoms may indicate hyperthyroidism resulting from excessive dosing of levothyroxine. Weight gain (Choice A) is a common symptom of hypothyroidism and may indicate undertreatment or inadequate dosing. Bradycardia (Choice B) is a symptom of hypothyroidism and may improve with levothyroxine therapy; it does not typically indicate an urgent need for healthcare provider notification. Fatigue (Choice D) is a symptom of hypothyroidism and can persist even with levothyroxine treatment, so it is not a symptom that would require immediate notification of the healthcare provider.
4. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?
- A. Assess the client's hemoglobin levels to determine if the client is in shock
- B. Call the surgeon and prepare to take the client back to the operating room
- C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
- D. No action is required as postoperative bleeding can be expected
Correct answer: C
Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.
5. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?
- A. Hoarseness of the voice
- B. Slight swelling at the incision site
- C. Tingling around the mouth
- D. Mild fever
Correct answer: C
Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.
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