adult health 2 exam 1 Adult Health 2 Exam 1 - Nursing Elites
Logo

Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

2. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

3. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?

Correct answer: C

Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.

4. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

5. The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?

Correct answer: C

Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.

Similar Questions

The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?
A nurse is developing a care plan for a client with chronic pain. What interventions should be included to help manage pain?
The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?
How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?
Which organ lies retroperitoneally?
ATI TEAS 7 Exam Overview

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 50,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access @ $69.99

HESI LPN Premium
$149.99/ 90 days

  • 50,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access @ $149.99