HESI LPN
Adult Health 1 Final Exam
1. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.
2. The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?
- A. Monitor bowel sounds
- B. Provide frequent oral care
- C. Encourage ambulation
- D. Measure abdominal girth
Correct answer: B
Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.
3. The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?
- A. 15 degrees
- B. 30 degrees
- C. 45 degrees
- D. 90 degrees
Correct answer: C
Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.
4. A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?
- A. Moon face, slow wound healing, muscle wasting, sodium and water retention
- B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
- C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
- D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
Correct answer: A
Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.
5. What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?
- A. Check tube placement before each feeding
- B. Flush the tube with water before and after each feeding
- C. Elevate the head of the bed to 30 degrees
- D. Administer the feeding at room temperature
Correct answer: A
Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.
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