HESI LPN
Adult Health 1 Final Exam
1. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
- A. Remove the catheter and apply direct pressure for 5 minutes.
- B. Initiate intravenous fluids as prescribed.
- C. Secure the catheter using aseptic technique.
- D. Notify the healthcare provider of the need to reposition the catheter.
Correct answer: B
Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.
2. A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?
- A. Acidosis
- B. Alkalosis
- C. Hyperkalemia
- D. Hypernatremia
Correct answer: B
Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.
3. The nurse is teaching a client about coronary artery disease (CAD) preventive health. Which behavior stated by the client indicates a need for additional information and teaching?
- A. Increasing physical activity.
- B. Eating a low-fat diet.
- C. Decreasing the number of cigarettes smoked per day.
- D. Monitoring blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Decreasing the number of cigarettes smoked per day is not sufficient for CAD prevention. Smoking cessation is crucial in reducing the risk of CAD. While increasing physical activity, eating a low-fat diet, and monitoring blood pressure regularly are all positive behaviors for CAD prevention, quitting smoking should be emphasized due to its significant impact on cardiovascular health.
4. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
- A. Use the planning step of the nursing process to prioritize client care delivery.
- B. Delegate all tasks to assistive personnel.
- C. Focus on completing tasks in the order they are assigned.
- D. Avoid using a checklist for daily tasks.
Correct answer: A
Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.
5. Following an amniocentesis, a nurse is caring for a client. The nurse should observe the client for which of the following complications?
- A. Hyperemesis
- B. Proteinuria
- C. Hypoxia
- D. Hemorrhage
Correct answer: D
Rationale: After an amniocentesis, the nurse should monitor the client for potential complications, with hemorrhage being a significant concern due to the invasive nature of the procedure. Hyperemesis (severe vomiting), proteinuria (excessive protein in the urine), and hypoxia (low oxygen levels) are not typically associated with amniocentesis and are less likely to occur compared to hemorrhage, which is a more common complication that requires prompt recognition and intervention.