HESI LPN
Adult Health Exam 1 Chamberlain
1. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?
- A. Use sterile technique for catheter care
- B. Ensure the catheter bag is below the level of the bladder
- C. Provide perineal care daily
- D. Change the catheter only when necessary
Correct answer: B
Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.
2. During a routine prenatal visit, a nurse measures a client’s fundal height at 26 weeks gestation. What should the fundal height be?
- A. Approximately 26 cm
- B. Between 24 to 28 cm
- C. Above the umbilicus by two finger widths
- D. Below the xiphoid process
Correct answer: B
Rationale: The correct answer is B: 'Between 24 to 28 cm.' Fundal height is expected to be approximately equal to the weeks of gestation, so at 26 weeks, the fundal height should typically range between 24 to 28 cm. Choice A is incorrect because fundal height is not an exact measurement of gestational age in centimeters. Choice C is incorrect as it provides a general description above the umbilicus, which is not specific to 26 weeks gestation. Choice D is incorrect as the fundal height would not reach below the xiphoid process at 26 weeks gestation.
3. A client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications. What should be emphasized?
- A. Avoiding spicy and fatty foods
- B. Eating small, frequent meals
- C. Avoiding meals before bedtime
- D. All of the above
Correct answer: D
Rationale: In managing GERD, dietary modifications play a significant role. Avoiding spicy and fatty foods helps reduce irritation, while eating small, frequent meals prevents overeating, which can trigger reflux. Avoiding meals before bedtime allows for better digestion and reduces the likelihood of acid reflux during the night. Therefore, all of the options (A, B, and C) are crucial in managing GERD symptoms, making choice D the correct answer.
4. The nurse is assessing a client with left-sided heart failure. Which symptom should the nurse expect to find?
- A. Peripheral edema
- B. Jugular vein distention
- C. Shortness of breath
- D. Weight gain
Correct answer: C
Rationale: Shortness of breath is a characteristic symptom of left-sided heart failure. In this condition, the heart's inability to effectively pump blood forward causes blood to back up into the lungs, leading to fluid accumulation. This fluid accumulation results in pulmonary congestion, manifesting as shortness of breath or difficulty breathing. Peripheral edema (choice A) is more commonly associated with right-sided heart failure, where fluid accumulates in the extremities. Jugular vein distention (choice B) is a sign of increased central venous pressure and is more indicative of right-sided heart failure. Weight gain (choice D) can be a general symptom of heart failure due to fluid retention, but shortness of breath is specifically related to left-sided heart failure.
5. A client with a diagnosis of hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide?
- A. Take the medication at bedtime.
- B. Take the medication with food.
- C. Report any symptoms of hyperthyroidism.
- D. Discontinue the medication if you feel well.
Correct answer: C
Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to report any symptoms of hyperthyroidism. Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate overtreatment or excessive dosing of levothyroxine. Prompt reporting of these symptoms is crucial to prevent serious complications. Choices A and B are not the most critical information related to levothyroxine administration. Instructing the client to take the medication at bedtime or with food can be important for adherence but is not as crucial as monitoring for signs of hyperthyroidism. Choice D is incorrect as discontinuing the medication if feeling well can lead to a relapse of hypothyroidism symptoms.
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