HESI LPN
Adult Health 1 Final Exam
1. During a severe asthma exacerbation in a client, what is the nurse's priority?
- A. Administer a rescue inhaler immediately
- B. Prepare for intubation
- C. Encourage deep breathing exercises
- D. Monitor oxygen saturation levels
Correct answer: A
Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.
2. A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?
- A. Increases heart rate
- B. Lowers blood pressure
- C. Dilates coronary arteries
- D. Reduces myocardial oxygen demand
Correct answer: C
Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.
3. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?
- A. Monitor for signs of infection
- B. Ensure the client is pain-free
- C. Assess for bleeding and arrhythmias
- D. Maintain a patent airway
Correct answer: D
Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.
4. Based on the documentation in the medical record, which action should the nurse implement next?
- A. Administer the rubella vaccine subcutaneously
- B. Observe the mother breastfeeding her infant
- C. Call the nursery for the infant's blood type result
- D. Administer Vicodin one tablet for pain
Correct answer: B
Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.
5. 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.
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