HESI LPN
Adult Health 2 Final Exam
1. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?
- A. Encourage increased oral fluids.
- B. Provide high-protein snacks.
- C. Change the wound dressing.
- D. Administer prescribed antibiotics.
Correct answer: D
Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.
2. A client with a history of chronic back pain is prescribed oxycodone for pain management. What is the most important instruction the nurse should provide?
- A. Take the medication with food to reduce stomach upset
- B. Avoid operating heavy machinery while taking this medication
- C. Increase physical activity to enhance pain relief
- D. Report any signs of respiratory depression immediately
Correct answer: D
Rationale: The correct answer is D: 'Report any signs of respiratory depression immediately.' Respiratory depression is a severe side effect of opioids like oxycodone and can be life-threatening. It is crucial for the nurse to instruct the client to report any signs such as slow or shallow breathing, difficulty breathing, or confusion. Choice A is incorrect as taking oxycodone with or without food does not significantly affect its efficacy. Choice B is incorrect because avoiding driving is important due to the potential impairment caused by oxycodone, but reporting respiratory depression is more critical. Choice C is incorrect as increasing physical activity may not always be suitable for individuals with chronic back pain and is not directly related to preventing respiratory depression.
3. A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete
- B. Take all prescribed medications as directed
- C. Schedule a follow-up appointment with the healthcare provider
- D. Wear a mask when in public places
Correct answer: B
Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.
4. A client is admitted with a diagnosis of pneumonia. Which intervention should the nurse implement to promote airway clearance?
- A. Administer bronchodilators as prescribed.
- B. Encourage increased fluid intake.
- C. Perform chest physiotherapy.
- D. Provide humidified oxygen.
Correct answer: B
Rationale: Encouraging increased fluid intake is the most appropriate intervention to promote airway clearance in a client with pneumonia. Adequate hydration helps to thin respiratory secretions, making it easier for the client to cough up and clear the airways. Administering bronchodilators (Choice A) may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy (Choice C) can be beneficial in certain cases but may not be the initial intervention for promoting airway clearance. Providing humidified oxygen (Choice D) can help improve oxygenation but does not specifically target airway clearance in pneumonia.
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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