HESI LPN
Adult Health 1 Final Exam
1. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?
- A. Aspirin to prevent further blood clotting
- B. High-flow oxygen
- C. Intravenous fluids
- D. Nitroglycerin
Correct answer: A
Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.
2. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)
- A. Posterior tibial artery
- B. Radial artery
- C. External iliac artery
- D. Dorsalis pedis artery
Correct answer: D
Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.
3. The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?
- A. Importance of maintaining neck stability
- B. How to care for the surgical drain
- C. Pain management strategies
- D. All of the above
Correct answer: D
Rationale: Providing preoperative teaching for a client undergoing a thyroidectomy is essential to prepare them for postoperative care. Information about the importance of maintaining neck stability is crucial to prevent complications such as strain on the surgical site. Teaching the client how to care for the surgical drain is important to prevent infections, ensure proper wound healing, and aid in monitoring postoperative recovery. Pain management strategies are vital to ensure the client's comfort and promote optimal recovery. Including all these aspects in preoperative teaching ensures the client is well-prepared for comprehensive postoperative care. Therefore, the correct answer is D because all these elements are essential components of postoperative care for a client undergoing a thyroidectomy. Choices A, B, and C are all important aspects of postoperative care that the nurse should include in the preoperative teaching session.
4. Which nursing activity is within the scope of practice for the practical nurse?
- A. Complete an admission assessment in the normal newborn nursery
- B. Discontinue a central venous catheter that has become dislodged
- C. Observe a client rotate the subcutaneous site for an insulin pump
- D. Monitor a continuous narcotic epidural for a postoperative client
Correct answer: C
Rationale: The correct answer is C: 'Observe a client rotate the subcutaneous site for an insulin pump.' This activity is within the scope of practice for a practical nurse as it involves observing and ensuring proper technique for using an insulin pump, which aligns with their training and responsibilities. Choices A, B, and D are beyond the typical scope of practice for a practical nurse. Completing an admission assessment for a newborn nursery is usually performed by a registered nurse. Discontinuing a dislodged central venous catheter and monitoring a narcotic epidural require advanced skills and knowledge, usually carried out by registered nurses or advanced practice nurses.
5. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
- A. Monitor the client's vital signs every 4 hours
- B. Assess the client's lower extremities for sensation
- C. Instruct the client to maintain bed rest
- D. Wash any paste from the client's hair and scalp
Correct answer: D
Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.
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