HESI LPN
Adult Health Exam 1
1. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?
- A. Instruct the client to sit or lie down
- B. Monitor blood pressure and pulse
- C. Administer an anti-dizziness medication
- D. Increase fluid intake
Correct answer: B
Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.
2. The family health care plan includes the following listed in sequence:
- A. objective, statement of the problem, intervention, and evaluation
- B. objectives, intervention, evaluation, and statement of the problem
- C. evaluation, statement of the problems, objectives, and interventions
- D. statement of the problems, objectives, intervention, and evaluation
Correct answer: D
Rationale: In a family health care plan, the correct sequence should start with identifying the problems (statement of the problems), setting objectives, planning interventions, and then evaluating the outcomes. This sequence ensures a logical and structured approach to healthcare planning. Choices A, B, and C are incorrect as they do not follow the logical order of healthcare planning steps.
3. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated.
- B. Do not smoke while using oxygen.
- C. Avoid wearing the oxygen during physical activity.
- D. Store oxygen tanks in a cool, dark place.
Correct answer: B
Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.
4. How should a healthcare provider address the nutritional needs of a child with chronic kidney disease?
- A. Increase protein intake
- B. Reduce sodium and phosphorus intake
- C. Promote a high-fat diet
- D. Encourage frequent sugary snacks
Correct answer: B
Rationale: Reducing sodium and phosphorus intake is crucial in managing chronic kidney disease in children because it helps prevent complications such as electrolyte imbalances and bone problems. High protein intake can actually be harmful to the kidneys in this condition as it can lead to increased waste production. A high-fat diet is not recommended as it can contribute to heart and blood vessel problems. Encouraging frequent sugary snacks can lead to further complications like obesity and diabetes, which are not beneficial for a child with chronic kidney disease.
5. When should discharge planning for a client experiencing an exacerbation of heart failure be initiated?
- A. During the admission process
- B. After the client is stabilized
- C. When the client expresses readiness to go home
- D. Just before the expected discharge date
Correct answer: A
Rationale: Discharge planning for a client with an exacerbation of heart failure should begin during the admission process. Initiating discharge planning early ensures a smooth transition and continuity of care for the client. Option B, after the client is stabilized, is not ideal because planning should start early to address potential barriers to discharge. Option C, when the client expresses readiness to go home, may be too late as discharge planning is a proactive process. Option D, just before the expected discharge date, does not allow enough time for comprehensive planning and coordination of post-discharge care needs.