HESI LPN
Adult Health 1 Exam 1
1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?
- A. Administer a high-flow oxygen mask.
- B. Position the client in a high-Fowler's position.
- C. Provide a high-carbohydrate diet.
- D. Encourage the client to cough and deep breathe.
Correct answer: B
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.
2. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?
- A. pH below 7.3
- B. Potassium of 5.0
- C. HCT of 60
- D. PaO2 of 79%
Correct answer: C
Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.
3. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. “Get up and change positions slowly.”
- B. “Avoid eating aged cheese and smoked meat.”
- C. “Report any unusual bruising or bleeding to the doctor immediately.”
- D. “Eat the same amount of foods that contain vitamin K every day.”
Correct answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
4. A client with HIV/AIDS is receiving zidovudine (Retrovir). The nurse should monitor the client for which of the following adverse effects?
- A. Hyperglycemia
- B. Anemia
- C. Hypertension
- D. Hypercalcemia
Correct answer: B
Rationale: The correct answer is B: Anemia. Zidovudine (Retrovir) can cause bone marrow suppression, leading to anemia. Monitoring for signs of anemia, such as fatigue, pallor, and shortness of breath, is crucial. Choice A, Hyperglycemia, is not a common adverse effect of zidovudine. Choice C, Hypertension, is not directly associated with zidovudine use. Choice D, Hypercalcemia, is also not a typical adverse effect of zidovudine.
5. After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?
- A. Administer the enema solution.
- B. Remove the enema tube from the client's rectum.
- C. Wrap the end of the enema tube with a disposable tissue.
- D. Insert the enema tube into the client's rectum.
Correct answer: B
Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.