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. 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.
3. A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach
- B. Monitor sodium intake
- C. Report any signs of weight gain
- D. Avoid excessive caffeine intake
Correct answer: B
Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.
4. 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.
5. 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.
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