HESI LPN
Adult Health 1 Final Exam
1. The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?
- A. Raise the bed to ensure the drainage bag remains off the floor
- B. Attach the drainage bag to the side rail instead of the bed frame
- C. Observe the appearance of the urine in the drainage tubing
- D. Secure the tubing to the client's gown instead of his abdomen
Correct answer: D
Rationale: The correct action for the nurse to implement is to secure the tubing to the client's gown instead of his abdomen. Securing the tubing to the client's abdomen can cause discomfort, trauma to the urethra, and increase the risk of infection. Attaching the drainage bag to the bed frame can lead to tension on the catheter, increasing the risk of dislodgement or trauma. Raising the bed does not address the issue of incorrect tubing securing. Observing the appearance of urine is important but secondary to ensuring proper tubing attachment.
2. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Maintain a consistent intake of vitamin K-rich foods
- C. Avoid all foods containing vitamin K
- D. Consume a high-protein diet
Correct answer: B
Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.
3. 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.
4. The nurse is caring for a client who is postoperative following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?
- A. Keep the client in a low Fowler's position.
- B. Maintain hip abduction with pillows.
- C. Encourage early ambulation.
- D. Place the client in a prone position.
Correct answer: B
Rationale: Maintaining hip abduction with pillows is the most important intervention to prevent dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and prevents excessive internal rotation, which can lead to dislocation. Keeping the client in a low Fowler's position (Choice A) does not provide the necessary support and stability for the hip joint. While early ambulation (Choice C) is important for preventing complications such as blood clots and promoting circulation, it is not the most crucial intervention for preventing dislocation. Placing the client in a prone position (Choice D) can be harmful and increase the risk of dislocation.
5. After a 26-year-old gravida 4, para 0 experienced a spontaneous abortion at 9 weeks gestation, how should the nurse intervene after observing the client crying softly one hour post dilation and curettage (D&C)?
- A. Offer to call the social worker to discuss the possibility of adoption
- B. Reassure the client that the infertility specialist can help
- C. Express sorrow for the client's grief and offer to sit with her
- D. Chart the vital signs and amount of vaginal bleeding
Correct answer: C
Rationale: After a traumatic experience like a spontaneous abortion, it is crucial for the nurse to provide emotional support. Expressing sorrow for the client's grief and offering to sit with her demonstrates empathy and allows the client to process her emotions. Options A and B focus on future possibilities and medical interventions, which may not be immediately appropriate. Option D, while important for monitoring the client's physical status, does not address the client's emotional needs at that moment.
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