HESI LPN
Adult Health 1 Final Exam
1. A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?
- A. Increases heart rate
- B. Lowers blood pressure
- C. Dilates coronary arteries
- D. Reduces myocardial oxygen demand
Correct answer: C
Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.
2. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?
- A. Assess the client's body image perception.
- B. Monitor the client's electrolyte levels.
- C. Evaluate the client's exercise habits.
- D. Assess the client's relationship with her family.
Correct answer: B
Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.
3. The nurse is planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis affecting the elbow. Which one of the following should be the priority?
- A. Limiting fluids
- B. Client-controlled analgesia
- C. Applying cold compresses to the elbow
- D. Performing passive range of motion exercises
Correct answer: B
Rationale: During a vaso-occlusive crisis in sickle cell disease, the priority intervention is effective pain management. Client-controlled analgesia allows the child to self-administer pain relief as needed, promoting comfort and reducing stress. Limiting fluids (choice A) is not appropriate in this scenario as hydration is essential to prevent complications. Cold compresses (choice C) may provide some comfort but do not address the underlying pain. Passive range of motion exercises (choice D) are contraindicated during a vaso-occlusive crisis due to the risk of further pain and tissue damage.
4. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?
- A. Review the healthcare worker's history for possible exposure to TB.
- B. Instruct the healthcare worker to return for a repeat test in 1 week.
- C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
- D. Document negative results in the healthcare worker's medical record.
Correct answer: D
Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.
5. A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
- B. A client with type 1 DM who uses an insulin pump
- C. A client who is receiving heparin and has an aPTT of 34 seconds
- D. A client with orthostatic hypotension receiving IV fluids
Correct answer: C
Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.