HESI LPN
Adult Health 1 Exam 1
1. During a home visit, a nurse finds that an elderly client is having trouble remembering to take their medications. What is the best intervention?
- A. Set up a pill organizer
- B. Involve family members in care
- C. Arrange for a home health aide
- D. Implement all of the above
Correct answer: D
Rationale: The best intervention when an elderly client is having trouble remembering to take their medications is to implement all of the above options. Setting up a pill organizer helps in organizing and remembering medication schedules. Involving family members in care ensures additional support and reminders. Arranging for a home health aide can provide direct assistance and supervision. Implementing all these strategies together can significantly improve medication adherence, especially in clients with memory issues. Each option plays a crucial role in addressing different aspects of the problem, making 'Implement all of the above' the most comprehensive and effective choice.
2. The nurse is assessing a client with an IV infusion of normal saline. The client reports pain and swelling at the IV site. What should the nurse do first?
- A. Slow the rate of infusion
- B. Apply a warm compress to the site
- C. Elevate the affected arm
- D. Discontinue the IV infusion
Correct answer: D
Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.
3. When teaching a diabetic client about foot care, what information is most important?
- A. Inspect feet daily
- B. Wear cotton socks
- C. Use lukewarm water to wash feet
- D. Cut nails straight across
Correct answer: A
Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.
4. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?
- A. Administer oxygen as prescribed
- B. Perform an ECG
- C. Obtain a detailed health history
- D. Monitor vital signs regularly
Correct answer: B
Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.
5. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
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