HESI LPN
Adult Health 1 Final Exam
1. 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.
2. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly
- B. Provide a complex carbohydrate snack
- C. Administer 50% dextrose intravenously
- D. Give 15 grams of a fast-acting carbohydrate
Correct answer: D
Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.
3. The healthcare provider is providing discharge instructions to a client with chronic heart failure. Which dietary recommendation is most appropriate?
- A. Increase fluid intake.
- B. Follow a low-sodium diet.
- C. Follow a high-protein diet.
- D. Increase sodium intake.
Correct answer: B
Rationale: The most appropriate dietary recommendation for a client with chronic heart failure is to follow a low-sodium diet. This helps manage the condition by reducing fluid retention and the workload on the heart. High fluid intake can lead to fluid overload and exacerbate heart failure symptoms. While protein is important for overall health, a high-protein diet is not specifically indicated for chronic heart failure. Increasing sodium intake is contraindicated in heart failure as it can worsen fluid retention and increase the workload on the heart.
4. 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.
5. When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?
- A. Slightly above the level of the heart
- B. At the level of the heart
- C. At a level of comfort for the client
- D. Below the level of the heart
Correct answer: B
Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.
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