HESI LPN
Adult Health Exam 1
1. A client reports feeling isolated and lonely two weeks after the death of a spouse. What is the most appropriate nursing intervention?
- A. Encourage talking about the spouse
- B. Provide information on grief counseling
- C. Suggest joining a support group
- D. All of the above
Correct answer: D
Rationale: During the grieving process, individuals may benefit from various interventions to cope with their emotions and feelings of isolation. Encouraging the client to talk about the deceased spouse can provide an outlet for their emotions. Providing information on grief counseling can offer professional support tailored to their needs. Suggesting joining a support group can help the client connect with others who are going through a similar experience, fostering a sense of belonging and understanding. By selecting 'All of the above' as the correct answer, it acknowledges the importance of utilizing multiple strategies to support the client's emotional health and facilitate the grieving process effectively. The other options alone may not address all aspects of the client's needs during this difficult time.
2. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?
- A. Administer an epinephrine injection
- B. Call for immediate medical help
- C. Monitor airway, breathing, and circulation
- D. All of the above
Correct answer: A
Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.
3. 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.
4. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?
- A. Administer antibiotics as prescribed.
- B. Encourage increased fluid intake.
- C. Perform chest physiotherapy.
- D. Provide humidified oxygen.
Correct answer: B
Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.
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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