HESI LPN
Adult Health Exam 1 Chamberlain
1. A client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications. What should be emphasized?
- A. Avoiding spicy and fatty foods
- B. Eating small, frequent meals
- C. Avoiding meals before bedtime
- D. All of the above
Correct answer: D
Rationale: In managing GERD, dietary modifications play a significant role. Avoiding spicy and fatty foods helps reduce irritation, while eating small, frequent meals prevents overeating, which can trigger reflux. Avoiding meals before bedtime allows for better digestion and reduces the likelihood of acid reflux during the night. Therefore, all of the options (A, B, and C) are crucial in managing GERD symptoms, making choice D the correct answer.
2. A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?
- A. It helps reduce the production of intestinal gases.
- B. It ensures clearer imaging by emptying the stomach.
- C. It prevents the risk of aspiration during the procedure.
- D. It is a standard procedure for all surgical interventions.
Correct answer: B
Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.
3. The nurse is preparing to administer a tuberculin skin test (TST). Which area of the body is the preferred site for this injection?
- A. Deltoid muscle
- B. Inner forearm
- C. Abdomen
- D. Thigh
Correct answer: B
Rationale: The inner forearm is the preferred site for administering a tuberculin skin test (TST) due to its easy accessibility, minimal hair interference, and good visibility of the injection site, allowing for accurate interpretation of the test results. The deltoid muscle, abdomen, and thigh are not preferred sites for a TST as they may not provide the optimal conditions required for the test. The deltoid muscle is commonly used for intramuscular injections, the abdomen may have varying subcutaneous fat thickness affecting the test, and the thigh may not provide the necessary visibility for accurate reading.
4. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report?
- A. Decreased sexual libido
- B. Amenorrhea
- C. Quickening
- D. Nocturia
Correct answer: B
Rationale: Amenorrhea is the absence of menstrual periods and is a common early sign of pregnancy, typically reported by a client who is 6 weeks pregnant. Decreased sexual libido (Choice A) may or may not be experienced in early pregnancy, but it is not as specific as amenorrhea. Quickening (Choice C) refers to fetal movements felt by the mother, which usually occurs around 18-20 weeks of pregnancy, not at 6 weeks. Nocturia (Choice D) is waking up at night to urinate and is not typically associated with early pregnancy.
5. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?
- A. Check the client's respiratory rate
- B. Assess the client's pain level
- C. Monitor the client's blood pressure
- D. Evaluate the client's level of consciousness
Correct answer: A
Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.
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