HESI LPN
Adult Health 2 Final Exam
1. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Send wound drainage for culture and sensitivity.
- B. Institute contact precautions for staff and visitors.
- C. Use standard precautions and wear a mask.
- D. Monitor the client's white blood cell count.
Correct answer: B
Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.
2. When a woman has miscarried in three or more consecutive pregnancies, it is referred to as which type of spontaneous abortion?
- A. Inevitable
- B. Missed
- C. Habitual
- D. Threatened
Correct answer: C
Rationale: The correct answer is C, 'Habitual.' Habitual abortion is defined as three or more consecutive miscarriages, making it the appropriate term for this situation. Choice A, 'Inevitable,' refers to a miscarriage that cannot be prevented. Choice B, 'Missed,' refers to a miscarriage where the fetus has died but has not been expelled. Choice D, 'Threatened,' refers to a situation where there is bleeding in early pregnancy but the cervix remains closed.
3. A client with a history of alcohol dependence tells the nurse that he has been sober for three months but has recently started drinking again. What should the nurse do next?
- A. Ask the client why he started drinking again.
- B. Provide information about support groups for sobriety.
- C. Discuss the consequences of drinking on his health.
- D. Encourage the client to express his feelings about relapse.
Correct answer: D
Rationale: Encouraging the client to express his feelings about relapse is the most appropriate action for the nurse to take in this situation. This approach allows the nurse to address the underlying emotions and factors contributing to the relapse. Choice A, asking the client why he started drinking again, may come across as judgmental and might not be as effective in exploring the client's emotions. Choice B, providing information about support groups, is important but should come after addressing the client's current emotional state. Choice C, discussing the consequences of drinking, may be necessary at some point, but initially, the focus should be on the client's feelings and emotions surrounding the relapse.
4. The healthcare provider is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the healthcare provider recommend?
- A. High protein, high calorie
- B. High carbohydrate, low fat
- C. High vitamin A, high vitamin E
- D. Fluid restricted, bland
Correct answer: A
Rationale: The correct answer is A: High protein, high calorie. An immobilized patient with impaired skin integrity requires a diet high in protein and calories to repair injured tissue and rebuild depleted protein stores. This helps in promoting wound healing and preventing further breakdown of the skin. Choices B, C, and D are incorrect because while vitamins and minerals are essential for overall health, in this case, the priority is on providing sufficient protein and calories to support healing and recovery in an immobilized patient with impaired skin integrity.
5. Which of the following is a function of carbohydrates in the body?
- A. They provide insulation and support for organs.
- B. They help regulate body temperature.
- C. They serve as the body's main structural components.
- D. They are the body's primary source of energy.
Correct answer: D
Rationale: The correct answer is D. Carbohydrates are the body's primary source of energy, fueling daily activities and bodily functions. Choice A is incorrect because insulation and organ support are primarily provided by adipose tissue and structural proteins, not carbohydrates. Choice B is incorrect because the regulation of body temperature is mainly controlled by processes like sweating and shivering, not carbohydrates. Choice C is incorrect because structural components like proteins are responsible for building tissues and organs, not carbohydrates.