HESI LPN
Adult Health 1 Final Exam
1. Based on the documentation in the medical record, which action should the nurse implement next?
- A. Administer the rubella vaccine subcutaneously
- B. Observe the mother breastfeeding her infant
- C. Call the nursery for the infant's blood type result
- D. Administer Vicodin one tablet for pain
Correct answer: B
Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.
2. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take?
- A. Make a copy of the incident report for personal records
- B. Identify the medication name and dosage administered to the client in the report
- C. Obtain an order from the client's provider to complete the report
- D. Include the time the medication error occurred in the report
Correct answer: B
Rationale: The correct answer is to identify the medication name and dosage administered to the client in the incident report. This information is crucial for accurate documentation and investigation of the medication error. Choice A is incorrect because incident reports are usually kept confidential and not for personal keeping. Choice C is incorrect as obtaining an order from the client's provider is not necessary to complete an incident report. Choice D, while important, is not the only essential information needed for the incident report.
3. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problem?
- A. Physical problems
- B. Relational problems
- C. Eating disorders
- D. Emotional problems
Correct answer: D
Rationale: The correct answer is D: 'Emotional problems.' Recurrent abdominal pain (RAP) in children is frequently associated with emotional factors rather than physical issues, relational problems, or eating disorders. Children may manifest emotional distress through physical symptoms like abdominal pain, making it crucial for nurses to assess for emotional problems as a potential cause.
4. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct answer: A
Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.
5. The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?
- A. Increase fiber intake.
- B. Avoid spicy foods.
- C. Avoid dairy products.
- D. Consume a high-fat diet.
Correct answer: B
Rationale: The most appropriate dietary recommendation for a client with peptic ulcer disease (PUD) is to avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of PUD. Increasing fiber intake may be beneficial for other gastrointestinal conditions but is not the primary concern for PUD. Avoiding dairy products is not a general recommendation for PUD unless the individual has a specific intolerance. Consuming a high-fat diet can increase the risk of exacerbating PUD symptoms due to the delayed gastric emptying associated with high-fat meals.