HESI LPN
Adult Health Exam 1 Chamberlain
1. A client who is 24 weeks pregnant presents with a complaint of feeling dizzy when lying on her back. What is the best response by the nurse?
- A. Advise the client to lie on her side
- B. Encourage the client to drink more fluids
- C. Suggest the client elevate her legs when lying down
- D. Recommend the client take short walks throughout the day
Correct answer: A
Rationale: The correct answer is to advise the client to lie on her side. Lying on the side can prevent the compression of the vena cava, which can cause dizziness in pregnant women. Encouraging the client to drink more fluids (Choice B) may be beneficial for other conditions but is not the best response for dizziness when lying on her back. Suggesting the client elevate her legs when lying down (Choice C) is not directly related to the issue described by the client. Recommending the client take short walks throughout the day (Choice D) may be helpful for other pregnancy-related symptoms but is not the most appropriate action for dizziness when lying on her back.
2. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?
- A. Place a 4x4 wick in the stoma opening
- B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
- C. Cut the bag opening to the measurement of the stoma size
- D. Administer a PRN antidiarrheal agent
Correct answer: C
Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.
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. During a tonic-clonic seizure, what is the nurse's priority intervention?
- A. Insert an oral airway
- B. Administer oxygen via nasal cannula
- C. Restrain the client's arms and legs
- D. Protect the client's head from injury
Correct answer: D
Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.
5. What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag only when necessary
- B. Eat a low-residue diet
- C. Assess the stoma for color and swelling
- D. Irrigate the colostomy only if advised by a healthcare provider
Correct answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.
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