HESI LPN
Adult Health 2 Exam 1
1. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?
- A. Take the medication with milk to enhance absorption
- B. Expect stools to be dark in color
- C. Take the medication before bedtime
- D. Avoid foods high in vitamin C
Correct answer: B
Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.
2. When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
- A. Press gently on the tragus of the client’s ear.
- B. Pull the ear lobe up and back.
- C. Insert the medication deeply into the ear canal.
- D. Massage the ear gently after administering the medication.
Correct answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client’s ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.
3. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The professional should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 107 mL/hr
- B. 120 mL/hr
- C. 95 mL/hr
- D. 100 mL/hr
Correct answer: A
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time (7 hr). 750 ÷ 7 ≈ 107 mL/hr. Choice A is correct because it accurately calculates the infusion rate based on the total volume and time. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate in this scenario.
4. A parent tells the nurse, “My 9-month-old baby no longer has the same strong grasp that was present at birth and no longer acts startled by loud noises.” How should the nurse explain these changes in behavior?
- A. “I will check these responses before deciding how to proceed.”
- B. “Failure of these responses may be related to a developmental delay.”
- C. “Additional sensory stimulation is needed to aid in the return of these responses.”
- D. “These responses are replaced by voluntary activity at about five months of age.”
Correct answer: D
Rationale: The correct answer is D. The grasp reflex and startle reflex (Moro reflex) are normal in newborns but typically disappear as the infant's nervous system matures and voluntary control develops. At around five months of age, these reflexes are replaced by voluntary movements as part of the normal developmental process. Choices A, B, and C are incorrect. Choice A suggests delaying a decision until further assessment, which is not necessary as the disappearance of these reflexes is a normal part of infant development. Choice B implies a developmental delay, which is not the case as these reflexes naturally disappear with age. Choice C recommending additional sensory stimulation is unnecessary and not the reason for the absence of these reflexes.
5. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.