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. Which membrane lines the abdominal cavity?
- A. Perineum
- B. Pericardium
- C. Pleura
- D. Peritoneum
Correct answer: D
Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.
3. A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?
- A. Neutralizes stomach acid
- B. Reduces gastric acid production
- C. Forms a protective barrier over ulcers
- D. Increases gastric mucus production
Correct answer: B
Rationale: The correct answer is B: Reduces gastric acid production. Omeprazole is a proton pump inhibitor that works by reducing gastric acid production, thereby helping to heal ulcers. While neutralizing stomach acid is associated with antacids, forming a protective barrier over ulcers is more characteristic of medications like sucralfate. The action described in choice D, increasing gastric mucus production, is not the primary mechanism of action of omeprazole in treating peptic ulcer disease.
4. The nurse observes that a post-operative client's surgical wound has reddened edges and is oozing. What is the appropriate nursing action?
- A. Apply an antibiotic ointment
- B. Clean the wound with sterile saline
- C. Cover the wound with a sterile dressing
- D. Notify the surgeon immediately
Correct answer: D
Rationale: The correct action when a post-operative client's surgical wound has reddened edges and is oozing is to notify the surgeon immediately. Reddened, oozing wound edges can indicate an infection that requires prompt evaluation and intervention by the surgical team. Applying an antibiotic ointment (Choice A) without proper assessment and guidance can be inappropriate. Cleaning the wound with sterile saline (Choice B) and covering it with a sterile dressing (Choice C) may not address the potential infection adequately, and the client may require more specialized care that the surgeon can provide.
5. 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.
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