HESI LPN
Adult Health Exam 1
1. During a routine prenatal visit, a nurse measures a client’s fundal height. The client is 26 weeks pregnant. What should the fundal height be?
- A. Approximately 26 cm
- B. Between 24 to 28 cm
- C. Above the umbilicus by two finger widths
- D. Below the xiphoid process
Correct answer: B
Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated
- B. Avoid wearing oxygen during physical activity
- C. Do not smoke while using oxygen
- D. Store oxygen tanks in a cool, dark place
Correct answer: C
Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.
3. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?
- A. Thrombocytopenia
- B. Polycythemia
- C. Decreased ESR
- D. Positive ASO titer
Correct answer: D
Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.
4. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
- A. A client who has a new diagnosis of adrenal insufficiency
- B. A client who has heart failure
- C. A client who is receiving treatment for diabetic ketoacidosis
- D. A client who has abdominal ascites
Correct answer: B
Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.
5. What is the primary symptom of a urinary tract infection in young children?
- A. Frequent urination
- B. Abdominal pain
- C. Vomiting
- D. Fever
Correct answer: D
Rationale: The correct answer is D, Fever. In young children, fever is a common primary symptom of a urinary tract infection, often accompanied by irritability and discomfort. Frequent urination (Choice A) is a symptom more commonly seen in adults with UTIs. While abdominal pain (Choice B) and vomiting (Choice C) can be present, they are not as primary as fever in young children with UTIs.