HESI LPN
Adult Health Exam 1 Chamberlain
1. The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?
- A. Notify the anesthesiologist
- B. Document the intake in the medical record
- C. Cancel the surgery
- D. Instruct the client to fast until the surgery
Correct answer: A
Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.
2. When using a metered-dose inhaler (MDI), which step is most important for ensuring effective medication delivery?
- A. Exhale completely before using the inhaler
- B. Inhale quickly while pressing down on the inhaler
- C. Shake the inhaler for 10 seconds before use
- D. Hold breath for 5 seconds after inhaling
Correct answer: A
Rationale: The correct step to ensure effective medication delivery when using a metered-dose inhaler (MDI) is to exhale completely before using the inhaler. This action helps create more space in the lungs for the medication to reach deeply into the airways. Inhaling quickly while pressing down on the inhaler (Choice B) may cause the medication to impact the throat rather than reaching the lungs. Shaking the inhaler for 10 seconds before use (Choice C) is important to mix the medication but not the most crucial step for effective delivery. While holding the breath for 5 seconds after inhaling (Choice D) can help the medication stay in the lungs momentarily, exhaling completely before inhalation is more critical for optimal drug deposition.
3. The healthcare provider is preparing to administer an intramuscular injection to an adult client. Which site is the preferred location for this injection?
- A. Deltoid muscle.
- B. Vastus lateralis muscle.
- C. Ventrogluteal muscle.
- D. Dorsogluteal muscle.
Correct answer: C
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.
4. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?
- A. The IV fluids are infusing into the subcutaneous tissues
- B. The infusion pump is functioning properly
- C. The insertion date should be verified and the IV discontinued
- D. The site is inflamed and should be reported
Correct answer: B
Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.
5. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?
- A. Administer oxygen as prescribed
- B. Perform an ECG
- C. Obtain a detailed health history
- D. Monitor vital signs regularly
Correct answer: B
Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.
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