HESI LPN
Adult Health 1 Final Exam
1. A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?
- A. Administer a bronchodilator as prescribed
- B. Encourage the client to drink fluids
- C. Place the client in an upright position
- D. Assess the client's peak flow rate
Correct answer: A
Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.
2. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?
- A. Decreased sexual libido
- B. Amenorrhea
- C. Quickening
- D. Nocturia
Correct answer: B
Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.
3. The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. What is the priority nursing intervention?
- A. Suction the tracheostomy as needed
- B. Ensure the tracheostomy ties are secure
- C. Provide humidified oxygen
- D. Clean any exudate around the tracheostomy site
Correct answer: A
Rationale: The priority nursing intervention for a client with a tracheostomy on mechanical ventilation is to suction the tracheostomy as needed. Suctioning is essential to maintain a clear airway and prevent respiratory distress. While ensuring tracheostomy ties are secure (choice B) is important, it is not as urgent as airway maintenance. Providing humidified oxygen (choice C) is beneficial but does not address the immediate need for airway clearance. Cleaning exudate around the tracheostomy site (choice D) is important for hygiene but takes precedence over ensuring airway patency through suctioning.
4. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?
- A. Take your insulin as usual
- B. Do not eat or drink after midnight
- C. Monitor your blood glucose closely
- D. Bring your glucose meter to the hospital
Correct answer: B
Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.
5. The client is being taught about a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Canned vegetables
- C. Fresh chicken
- D. Unsalted nuts
Correct answer: B
Rationale: The correct answer is B: Canned vegetables. Canned vegetables are often high in sodium due to the preservation process, so they should be avoided on a low-sodium diet. Fresh fruits (choice A), fresh chicken (choice C), and unsalted nuts (choice D) are all low-sodium options and can be included in a low-sodium diet. It is important to choose fresh or frozen vegetables over canned ones to reduce sodium intake. Fresh chicken and unsalted nuts are also good protein sources that are naturally low in sodium, making them suitable for a low-sodium diet. Therefore, clients following a low-sodium diet should prioritize fresh, whole foods over processed or canned options.
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