HESI LPN
Adult Health 2 Final Exam
1. 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.
2. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago. To confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct answer: D
Rationale: The PPD (purified protein derivative) intradermal test is the standard screening method for detecting tuberculosis infection. It helps identify individuals who have been infected with Mycobacterium tuberculosis. A chest x-ray (Choice A) is used to assess the extent of active disease, not for screening purposes. Blood culture (Choice B) is not typically used for tuberculosis screening. Sputum culture (Choice C) is used to confirm active tuberculosis in symptomatic individuals, not for initial screening purposes.
3. Monozygotic (MZ) twins are known as fraternal twins.
- A. TRUE
- B. FALSE
- C. Possibly
- D. Never
Correct answer: B
Rationale: The correct answer is B: 'FALSE.' Monozygotic (MZ) twins are identical twins, not fraternal. Fraternal twins are dizygotic (DZ). The statement in the question is incorrect as MZ twins are genetically identical, while fraternal twins actually refer to dizygotic twins who develop from two separate fertilized eggs. Therefore, monozygotic twins are not known as fraternal twins, making option B the correct choice. Options A, C, and D are incorrect as they do not accurately describe the relationship between monozygotic and fraternal twins.
4. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the CDC?
- A. 13-18 years of age
- B. 11-12 years of age
- C. 18-24 months of age
- D. 4-6 years of age
Correct answer: D
Rationale: The correct answer is D: 4-6 years of age. The CDC recommends administering the MMR booster to children aged 4 to 6 years. This booster dose is essential to ensure continued immunity against measles, mumps, and rubella. Choices A, B, and C are incorrect because they do not align with the CDC guidelines for the age range of MMR booster administration.
5. An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?
- A. obtain a serum potassium level
- B. administer the client's usual dose of insulin
- C. assess pupillary response to light
- D. Start an intravenous (IV) infusion of normal saline
Correct answer: D
Rationale: Administering IV fluids is crucial to address potential dehydration and electrolyte imbalances, especially if the client is unable to provide a clear history. Starting an IV infusion of normal saline will help rehydrate the client and address any electrolyte imbalances, which are common in clients with diabetes experiencing symptoms like abdominal cramping and vomiting. Obtaining a serum potassium level can be important but is not the priority when the client is showing signs of dehydration and confusion. Administering insulin should only be done after addressing hydration and electrolyte status. Assessing pupillary response to light is not the most critical action in this situation compared to addressing dehydration and potential electrolyte imbalances.