HESI LPN
Adult Health 1 Exam 1
1. A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated
- B. Avoid wearing oxygen during physical activity
- C. Do not smoke while using oxygen
- D. Store oxygen tanks in a cool, dark place
Correct answer: C
Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.
2. When assessing a child with suspected nephrotic syndrome, what clinical manifestation is the nurse likely to observe?
- A. Jaundice
- B. Edema
- C. Hypertension
- D. Polyuria
Correct answer: B
Rationale: Edema is a hallmark clinical manifestation of nephrotic syndrome. In nephrotic syndrome, there is increased glomerular permeability leading to the loss of proteins, particularly albumin, in the urine. This results in decreased oncotic pressure, leading to fluid shifting into the interstitial spaces and causing edema. Jaundice (Choice A) is not a typical clinical manifestation of nephrotic syndrome. Hypertension (Choice C) is more commonly associated with conditions like glomerulonephritis. Polyuria (Choice D) is not a primary symptom of nephrotic syndrome; instead, patients may have reduced urine output due to fluid retention from edema.
3. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?
- A. No bowel movement for two days
- B. Mother helps reposition the child
- C. Ensure weights are not touching the foot of the bed
- D. Child wiggles toes freely when tickled
Correct answer: C
Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.
4. The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate?
- A. An excess of red blood cells
- B. An excess of white blood cells
- C. A deficiency of clotting factor VIII
- D. A deficiency of clotting factors VIII and IX
Correct answer: C
Rationale: The correct answer is C: A deficiency of clotting factor VIII. Hemophilia A is characterized by a lack of clotting factor VIII, which is crucial for blood clotting. This deficiency results in prolonged bleeding. Choices A, B, and D are incorrect. There is no association between Hemophilia A and an excess of red blood cells (Choice A) or an excess of white blood cells (Choice B). Additionally, Hemophilia A specifically involves a deficiency of clotting factor VIII, not both factors VIII and IX (Choice D).
5. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:
- A. Sit and hold the client’s hand
- B. Ask why the client is crying
- C. Leave the room to give the client privacy
- D. Administer the medications and leave
Correct answer: A
Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.