HESI LPN
Adult Health Exam 1
1. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
2. A client with chronic kidney disease is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Decreased urine output
- B. Weight loss of 1 kg
- C. Blood pressure of 150/90 mm Hg
- D. Presence of a bruit over the fistula
Correct answer: C
Rationale: The correct answer is C. An elevated blood pressure in clients with chronic kidney disease undergoing hemodialysis can indicate fluid overload or poor dialysis efficacy and should be reported immediately. This finding could lead to complications such as heart failure or pulmonary edema. Choices A, B, and D are not as critical in this situation. Decreased urine output may be expected due to the kidney disease, a weight loss of 1 kg is within an acceptable range, and the presence of a bruit over the fistula is a common finding in clients undergoing hemodialysis and does not require immediate reporting.
3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
- A. Administer bronchodilator therapy as prescribed.
- B. Inhale the medication slowly while pressing down on the inhaler.
- C. Position the client in a high-Fowler's position.
- D. Increase the oxygen flow rate.
Correct answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing by maximizing chest expansion and allowing for better airflow. While administering bronchodilator therapy is important, positioning the client for improved breathing takes priority. Inhaling the medication slowly and pressing down on the inhaler is a correct technique for inhaler use but not the priority intervention. Increasing the oxygen flow rate may be needed, but adjusting the client's position to a high-Fowler's position is the priority to address the shortness of breath in COPD.
4. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?
- A. Check the client’s blood type compatibility
- B. Monitor the client for signs of transfusion reaction
- C. Verify the correct client and blood product with another healthcare professional
- D. All of the above
Correct answer: D
Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.
5. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?
- A. Administer morphine for pain relief
- B. Encourage the client to perform isometric exercises
- C. Position the client flat in bed
- D. Restrict fluid intake
Correct answer: A
Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.
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