HESI LPN
Adult Health 2 Final Exam
1. 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.
2. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...
- A. Short of breath after a shower and has a hemoglobin of 8 grams
- B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
- C. Febrile and has a WBC count of 14,000/mm3
- D. Trembling and has a glucose level of 50 mg/dL
Correct answer: D
Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.
3. The nurse is caring for a client who has just returned from surgery with a urinary catheter in place. What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs)?
- A. Irrigate the catheter daily
- B. Ensure the catheter bag is always below bladder level
- C. Change the catheter every 48 hours
- D. Administer prophylactic antibiotics
Correct answer: B
Rationale: The correct answer is to ensure the catheter bag is always below bladder level. This positioning helps prevent backflow of urine, reducing the risk of CAUTIs. Choice A, irrigating the catheter daily, is not recommended as it can introduce pathogens into the bladder. Changing the catheter too frequently (Choice C) can increase the risk of introducing pathogens. Administering prophylactic antibiotics (Choice D) is not the primary intervention for preventing CAUTIs and can lead to antibiotic resistance.
4. The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?
- A. Encourage early ambulation
- B. Apply ice to the surgical site
- C. Monitor the surgical site for signs of infection
- D. Administer pain medication as prescribed
Correct answer: A
Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.
5. 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.
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