HESI LPN
Adult Health 2 Exam 1
1. After delivering a healthy newborn, a client is experiencing postpartum hemorrhage. What initial intervention should the nurse implement?
- A. Administer IV fluids
- B. Perform a uterine massage
- C. Monitor the newborn's vital signs
- D. Notify the healthcare provider
Correct answer: B
Rationale: The correct initial intervention for postpartum hemorrhage is to perform a uterine massage. This action helps the uterus contract, controlling bleeding. Administering IV fluids may be necessary but is not the initial intervention. Monitoring the newborn's vital signs is important but not the priority when managing postpartum hemorrhage. Notifying the healthcare provider can be done after initiating immediate interventions to address the hemorrhage.
2. Which organ lies retroperitoneally?
- A. Kidneys
- B. Testicles
- C. Urinary bladder
- D. Pancreas
Correct answer: A
Rationale: The correct answer is A: Kidneys. The kidneys are located retroperitoneally, behind the peritoneum, providing structural protection and maintaining a stable position within the abdominal cavity. This location helps protect them from external physical trauma. Choices B, C, and D are incorrect because testicles, urinary bladder, and pancreas are not located retroperitoneally. Testicles are located in the scrotum, the urinary bladder is located in the pelvis, and the pancreas is located in the upper abdomen, not retroperitoneally.
3. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
4. The healthcare provider is assessing a client with a suspected diagnosis of appendicitis. Which symptom is most indicative of this condition?
- A. Right upper quadrant pain
- B. Nausea and vomiting
- C. Rebound tenderness at McBurney's point
- D. Hematuria
Correct answer: C
Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This symptom is due to irritation of the peritoneum when pressure is released during palpation. Right upper quadrant pain (Choice A) is more commonly associated with gallbladder issues. Nausea and vomiting (Choice B) can occur in various abdominal conditions and are not specific to appendicitis. Hematuria (Choice D) is the presence of blood in the urine and is not a typical symptom of appendicitis.
5. Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who
- A. is immobile on prescribed bedrest.
- B. has pressure ulcers on several toes.
- C. has diminished pedal pulse volume.
- D. is confused and trying to climb out of bed.
Correct answer: A
Rationale: The correct answer is A. Pneumatic compression devices are most beneficial for immobile clients on prescribed bedrest to prevent deep vein thrombosis. Applying these devices helps in promoting circulation and preventing blood clots. Choices B, C, and D do not specifically relate to the primary indication for pneumatic compression devices, making them incorrect. Pressure ulcers, diminished pedal pulse volume, and confusion with climbing out of bed may require different interventions or treatments.
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