HESI LPN
Adult Health Exam 1
1. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?
- A. 15 mL
- B. 10 mL
- C. 20 mL
- D. 5 mL
Correct answer: A
Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.
2. A client with a history of hypertension is prescribed lisinopril. Which potential side effect should the nurse monitor for?
- A. Hypokalemia
- B. Hyperglycemia
- C. Persistent cough
- D. Tachycardia
Correct answer: C
Rationale: The correct answer is C: Persistent cough. Lisinopril is an ACE inhibitor commonly associated with a persistent dry cough as a side effect. This cough is thought to result from increased bradykinin levels. Choices A, B, and D are incorrect. Hypokalemia is not a common side effect of lisinopril; in fact, it may lead to hyperkalemia. Hyperglycemia is not a typical side effect of lisinopril use. Tachycardia is also not a common side effect associated with ACE inhibitors like lisinopril.
3. The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?
- A. Raise the bed to ensure the drainage bag remains off the floor
- B. Attach the drainage bag to the side rail instead of the bed frame
- C. Observe the appearance of the urine in the drainage tubing
- D. Secure the tubing to the client's gown instead of his abdomen
Correct answer: D
Rationale: The correct action for the nurse to implement is to secure the tubing to the client's gown instead of his abdomen. Securing the tubing to the client's abdomen can cause discomfort, trauma to the urethra, and increase the risk of infection. Attaching the drainage bag to the bed frame can lead to tension on the catheter, increasing the risk of dislodgement or trauma. Raising the bed does not address the issue of incorrect tubing securing. Observing the appearance of urine is important but secondary to ensuring proper tubing attachment.
4. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?
- A. Take the medication with milk to enhance absorption
- B. Expect stools to be dark in color
- C. Take the medication before bedtime
- D. Avoid foods high in vitamin C
Correct answer: B
Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.
5. A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?
- A. Phlebitis
- B. Infiltration
- C. Allergic reaction
- D. Fluid overload
Correct answer: A
Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.
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