HESI LPN
Adult Health 1 Exam 1
1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
- A. Administer bronchodilator therapy as prescribed
- B. Encourage deep breathing and coughing exercises
- C. Position the client in a high-Fowler's position
- D. Increase the oxygen flow rate
Correct answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.
2. A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform further assessment in a 2-month-old infant with Down syndrome. This finding may indicate cardiac or respiratory issues, such as inadequate oxygenation. Small, low-set ears and a protruding furrowed tongue are common physical characteristics associated with Down syndrome and may not necessarily warrant immediate further assessment. A flat occiput is a normal variation in infant anatomy and is not typically a cause for immediate concern in this context.
3. Which toy is most appropriate for an 18-month-old child?
- A. A pull toy
- B. A puzzle with large pieces
- C. A book with large pictures
- D. A doll with small clothes
Correct answer: A
Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.
4. During a nap, a 3-year-old hospitalized child wets the bed. How should the nurse respond?
- A. Ask the child to help with remaking the bed.
- B. Put clean sheets on the bed over a rubber sheet.
- C. Change the child’s clothes without discussing the incident.
- D. Explain that children should call the nurse when they need to go to the bathroom.
Correct answer: C
Rationale: When a 3-year-old hospitalized child wets the bed during a nap, the nurse should respond by changing the child's clothes without discussing the incident. This approach helps to maintain the child's dignity, avoid embarrassment, and reduce anxiety about bedwetting. Asking the child to help remake the bed (Choice A) may not be developmentally appropriate for a 3-year-old and could potentially lead to further distress. Putting clean sheets on the bed over a rubber sheet (Choice B) addresses the aftermath but does not directly address the child's needs and feelings. Explaining that children should call the nurse when they need to go to the bathroom (Choice D) may not be effective in this situation as the child may not have control over bedwetting during sleep.
5. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach and phase the nurse manager should
- A. Discuss with the staff how to deal with any defensive behavior
- B. Explain to the unit staff why change is necessary
- C. Assist the staff during the acceptance of the new changes
- D. Clarify what the changes mean to the community and hospital
Correct answer: B
Rationale: The "unfreezing" phase involves preparing staff for change by explaining the necessity and benefits of the change, helping them to understand and accept it.