HESI LPN
Adult Health 2 Final Exam
1. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?
- A. Use the inhaler only during an asthma attack
- B. Rinse your mouth after using the inhaler
- C. Shake the inhaler before each use
- D. Exhale fully before inhaling the medication
Correct answer: C
Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.
2. The wife is observed shaving her husband's beard with a safety razor. What should the nurse do?
- A. Advise the wife to shave against the hair growth
- B. Teach the wife to keep the skin loose to avoid cuts
- C. Encourage the wife to continue shaving her husband
- D. Demonstrate the correct procedure to the wife
Correct answer: C
Rationale: In this situation, the nurse should encourage the wife to continue shaving her husband. The rationale behind this is that the wife is already performing the task, so abrupt interference may lead to potential harm or emotional distress. It is crucial for the nurse to carefully observe the situation and assess for any safety concerns. While teaching proper techniques (Choice B) is important, it can be addressed later in a non-critical manner to prevent skin irritation and injury. Advising to shave against the hair growth (Choice A) may cause skin irritation and cuts. Although demonstrating the correct procedure (Choice D) may be helpful, it is essential to consider the current dynamics and respect the wife's autonomy in caring for her husband.
3. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?
- A. Restrict fluid intake
- B. Provide a high-sodium diet
- C. Encourage vigorous exercise
- D. Administer bronchodilators as prescribed
Correct answer: A
Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.
4. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Maintain a consistent intake of vitamin K-rich foods
- C. Avoid all foods containing vitamin K
- D. Consume a high-protein diet
Correct answer: B
Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.
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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