HESI LPN
Adult Health 2 Final Exam
1. What is the primary purpose of a chest tube in a client's care?
- A. To drain air and fluid from the pleural space
- B. To prevent infection in the thoracic cavity
- C. To assist with lung expansion
- D. To monitor intrathoracic pressure
Correct answer: A
Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.
2. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?
- A. Administer antibiotics as prescribed
- B. Perform chest physiotherapy
- C. Encourage increased fluid intake
- D. Provide humidified oxygen
Correct answer: C
Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.
3. A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?
- A. The neck extended backward using a rolled towel behind the neck
- B. Prone position using pillows to support both arms outward from the torso
- C. Side-lying position using pillows to support the abdomen and back
- D. The neck forward using pillows under the head and sandbags on both sides
Correct answer: D
Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.
4. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?
- A. Serum glucose of 180 mg/dL
- B. Blood pH of 7.30
- C. Positive urine ketones
- D. Serum bicarbonate of 25 mEq/L
Correct answer: C
Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.
5. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?
- A. Use the inhaler only during an asthma attack
- B. Rinse your mouth after using the inhaler
- C. Shake the inhaler before each use
- D. Exhale fully before inhaling the medication
Correct answer: C
Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.
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