HESI LPN
Adult Health 1 Final Exam
1. A client with a history of stroke presents with dysphagia. What is the most important nursing intervention to prevent aspiration?
- A. Encourage the client to drink water between meals
- B. Position the client in a high-Fowler's position during meals
- C. Provide the client with thickened liquids
- D. Allow the client to eat quickly
Correct answer: B
Rationale: The correct answer is B: Position the client in a high-Fowler's position during meals. Placing the client in a high-Fowler's position (sitting upright at a 90-degree angle) helps reduce the risk of aspiration by ensuring that the airway is protected during swallowing. This position facilitates easier swallowing and decreases the likelihood of food or liquids entering the respiratory tract. Encouraging the client to drink water between meals (choice A) does not directly address the risk of aspiration during meals. Providing thickened liquids (choice C) may be necessary for some patients with dysphagia but is not the most important intervention to prevent aspiration. Allowing the client to eat quickly (choice D) without proper positioning and precautions can increase the risk of aspiration.
2. Which of the following is the best argument for lower patient-to-nurse ratio?
- A. The more patients a nurse has, the better the nurse will be at catching early warning signs.
- B. Greater patient-to-nurse ratios decrease patient mortality.
- C. Adequate nurse levels do not impact the prevalence of urinary tract infections.
- D. Community nursing ratios do not impact Methicillin-resistant Staphylococcus aureus (MRSA) rates.
Correct answer: B
Rationale: The best argument for lower patient-to-nurse ratios is that they decrease patient mortality. Choice A is incorrect because having more patients can lead to increased workload and decreased attention per patient. Choice C is incorrect as adequate nurse levels can indeed impact the prevalence of infections. Choice D is incorrect as community nursing ratios can impact MRSA rates due to potential transmission risks in healthcare settings.
3. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The LPN/LVN notes that the client has not bathed or dressed in clean clothes for several days. What is the most appropriate intervention for the nurse to implement?
- A. Encourage the client to take a shower.
- B. Assist the client with activities of daily living.
- C. Provide the client with clean clothes to change into.
- D. Explain the importance of personal hygiene to the client.
Correct answer: B
Rationale: The correct answer is to assist the client with activities of daily living. This intervention is the most appropriate as it directly addresses the client's immediate needs by providing assistance with personal hygiene and dressing. It promotes self-care and ensures the client's well-being. Encouraging the client to take a shower (Choice A) may not be effective if the client is unable to do so independently due to their condition. Providing clean clothes (Choice C) is important but does not address the client's need for assistance with personal care. Explaining the importance of personal hygiene (Choice D) may not be as effective as providing direct assistance in this situation.
4. What dietary recommendation should be made to a child with iron-deficiency anemia?
- A. Increase intake of dairy products
- B. Include high-iron foods like spinach and meat
- C. Decrease protein intake
- D. Avoid all grains
Correct answer: B
Rationale: The correct recommendation for a child with iron-deficiency anemia is to include high-iron foods like spinach, red meat, and beans in their diet. These foods are rich sources of iron and can help address the deficiency. Choice A is incorrect as dairy products do not provide significant iron content. Choice C is incorrect because protein intake does not need to be decreased; in fact, lean meats are good sources of iron. Choice D is also incorrect as whole grains can be a part of a healthy diet and do not need to be avoided in this case.
5. A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
- A. Apply vest restraints to residents who are confused
- B. Keep all four side rails up on beds at night
- C. Accompany residents over 85 years of age during ambulation
- D. Implement rounds every 2 hours during the day to offer toileting
Correct answer: D
Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.