HESI LPN
Adult Health Exam 1
1. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?
- A. Place a new pad and weigh the pad removed to determine blood loss.
- B. Massage the fundus and express clots.
- C. Start an IV and begin an oxytocin infusion.
- D. Clean the perineal area and encourage her to breastfeed.
Correct answer: B
Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.
2. The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Dorsogluteal muscle
- D. Vastus lateralis muscle
Correct answer: D
Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in infants due to its size and safety. The deltoid muscle is typically used for adults and older children. The ventrogluteal muscle is more commonly used in toddlers and older children. The dorsogluteal muscle is not recommended for intramuscular injections in any age group due to its proximity to major nerves and blood vessels, which poses a risk of injury or sciatic nerve damage.
3. The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?
- A. Explain the benefits of ambulation for recovery
- B. Wait for the client to request to walk
- C. Tell the client that walking is necessary for discharge
- D. Offer pain medication before walking
Correct answer: A
Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.
4. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
- A. Monitor the client's vital signs every 4 hours
- B. Assess the client's lower extremities for sensation
- C. Instruct the client to maintain bed rest
- D. Wash any paste from the client's hair and scalp
Correct answer: D
Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.
5. A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?
- A. Ask the client about any allergies to medications
- B. Review the purposes of each medication
- C. Check for potential drug interactions
- D. All of the above
Correct answer: D
Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.
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