HESI LPN
Adult Health Exam 1 Chamberlain
1. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?
- A. Encourage the client to eat foods high in protein
- B. Assess the client for daily range of motion exercises
- C. Teach the family how to perform sterile wound care
- D. Ensure the IV fluids are administered as prescribed
Correct answer: A
Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.
2. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT levels
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct answer: D
Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.
3. A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Beta-lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump?
- A. 50
- B. 67
- C. 57
- D. 70
Correct answer: B
Rationale: To calculate the infusion rate for vancomycin, you need to divide the total volume by the total time of infusion. In this case, the total volume is 100 mL, and the total time is 1.5 hours. Therefore, 100 mL ÷ 1.5 hours = 67 mL/hour. This means the nurse should program the infusion pump to deliver vancomycin at a rate of 67 mL/hour. Choice A (50) is incorrect as it does not reflect the correct calculation. Choice C (57) is incorrect as it is not the accurate calculation based on the provided information. Choice D (70) is incorrect as it does not correspond to the correct infusion rate calculation.
4. 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.
5. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?
- A. Recheck the radial pulse in thirty minutes
- B. Palpate the radial pulse for thirty seconds and double the rate
- C. Count the apical pulse rate for sixty seconds
- D. Compare the radial pulse rate bilaterally and record the higher rate
Correct answer: C
Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.
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