HESI LPN
Adult Health 1 Final Exam
1. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?
- A. Irrigate the catheter daily.
- B. Change the catheter every 72 hours.
- C. Apply antibiotic ointment at the insertion site.
- D. Ensure the catheter bag is always below bladder level.
Correct answer: D
Rationale: The most crucial action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter is to ensure that the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Irrigating the catheter daily (Choice A) is unnecessary and can introduce pathogens. Changing the catheter every 72 hours (Choice B) is not recommended unless clinically indicated to prevent introducing new pathogens. Applying antibiotic ointment at the insertion site (Choice C) is not the most important action to prevent CAUTIs; proper hygiene and maintaining a closed system are more critical.
2. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?
- A. Measure the amount of a client's residual urine after voiding
- B. Cleanse the perineal area of a client with urinary incontinence
- C. Insert a straight catheter to obtain a urine specimen for culture
- D. Provide catheter care for a client with a suprapubic catheter
Correct answer: B
Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.
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. The client with chronic kidney disease (CKD) is being educated about dietary modifications. Which dietary restriction should the nurse emphasize the most?
- A. Limit intake of high-fiber foods
- B. Restrict protein intake
- C. Avoid dairy products
- D. Increase fluid intake
Correct answer: B
Rationale: The most crucial dietary restriction to emphasize for a client with chronic kidney disease (CKD) is to restrict protein intake. By restricting protein intake, the workload on the kidneys is reduced, which helps slow the progression of CKD. While high-fiber foods are generally beneficial, they may need to be limited in some individuals with CKD due to potassium concerns, making choice A less critical. Avoiding dairy products may be necessary in some cases to control phosphorus levels, but it is not as vital as restricting protein intake. Increasing fluid intake is essential for kidney health, but it is not the most critical dietary modification for clients with CKD.
5. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?
- A. Administration of IV diuretics
- B. Oxygen therapy
- C. Bed rest
- D. Dietary consultation
Correct answer: B
Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.
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