HESI LPN
Adult Health 2 Final Exam
1. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?
- A. Check for tightness of the cast
- B. Elevate the limb
- C. Apply ice to the area
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.
2. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?
- A. Bilateral leg swelling.
- B. Sudden onset of chest pain.
- C. Gradual onset of dyspnea.
- D. Decreased breath sounds on auscultation.
Correct answer: C
Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.
3. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?
- A. It helps reduce the production of intestinal gases.
- B. It ensures clearer imaging by emptying the stomach.
- C. It prevents the risk of aspiration during the procedure.
- D. It is a standard procedure for all surgical interventions.
Correct answer: B
Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.
4. A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?
- A. Starting an exercise program
- B. Keeping a sleep diary
- C. Practicing relaxation techniques before bed
- D. Using sleep-inducing medications at night
Correct answer: C
Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.
5. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?
- A. Apply an ice pack
- B. Document the findings and monitor
- C. Notify the surgeon
- D. Clean the wound with sterile saline
Correct answer: C
Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.
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