HESI LPN
Adult Health Exam 1
1. A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?
- A. Administer insulin as prescribed
- B. Encourage fluid intake
- C. Monitor blood glucose levels frequently
- D. Assess for signs of hypoglycemia
Correct answer: A
Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.
2. A client requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Help the client take sips of water to promote insertion of the NG tube.
- B. Insert the tube without asking the client to swallow.
- C. Advance the tube continuously without pausing.
- D. Use a large-bore tube for insertion.
Correct answer: A
Rationale: The correct action when inserting an NG tube is to help the client take sips of water. This helps facilitate the insertion of the tube by promoting swallowing and passage through the esophagus. Asking the client to swallow assists in guiding the tube into the stomach. Inserting the tube without asking the client to swallow may lead to incorrect placement or discomfort. Advancing the tube continuously without pausing can cause the tube to coil in the esophagus, leading to complications. Using a large-bore tube for insertion is unnecessary and may increase the risk of injury or discomfort for the client.
3. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the brace
- D. Spending a majority of their time with her
Correct answer: C
Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.
4. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?
- A. Obtain a blood sample to determine if the client is HIV positive
- B. Send the family to the waiting area while conducting a head-to-toe assessment
- C. Complete a head-to-toe assessment to identify other signs of HIV
- D. Ask the family members to wear gloves when touching the client
Correct answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.
5. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?
- A. Thickened formula 24 hours after surgery
- B. Withholding feedings for the first 24 hours
- C. Regular formula feeding within 24 hours after surgery
- D. Additional glucose feedings as desired after the first 24 hours
Correct answer: C
Rationale: After surgery for hypertrophic pyloric stenosis (HPS), it is appropriate to resume regular formula feeding within 24 hours postoperatively to promote recovery. Choice A, thickened formula after surgery, may be too heavy for the infant's digestive system at this early stage. Withholding feedings for the first 24 hours (Choice B) is not recommended as early feeding helps with recovery. Additional glucose feedings (Choice D) are not necessary and may not provide the balanced nutrition required after surgery.