HESI LPN
Adult Health Exam 1 Chamberlain
1. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?
- A. International Normalized Ratio (INR)
- B. Blood glucose levels
- C. Blood pressure
- D. Temperature
Correct answer: A
Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.
2. 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.
3. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?
- A. Aspirin to prevent further blood clotting
- B. High-flow oxygen
- C. Intravenous fluids
- D. Nitroglycerin
Correct answer: A
Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.
4. A client is prescribed warfarin (Coumadin) for atrial fibrillation. Which dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Avoid foods high in vitamin K
- C. Increase intake of foods rich in vitamin C
- D. Limit intake of dairy products
Correct answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Vitamin K can decrease the effectiveness of warfarin, so it is essential for clients on warfarin therapy to avoid foods high in vitamin K. Green leafy vegetables are high in vitamin K, so choice A is incorrect. Choices C and D are unrelated to the dietary restrictions needed for clients taking warfarin and are therefore incorrect.
5. Which nonfood item is the most common cause of respiratory arrest in young children?
- A. Broken rattles
- B. Buttons
- C. Pacifiers
- D. Latex balloons
Correct answer: D
Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.
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