the nurse is assessing a client with chronic obstructive pulmonary disease copd who is experiencing shortness of breath what is the priority nursing i
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Nursing Elites

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?

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. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?

Correct answer: A

Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.

3. A client with a urinary tract infection is prescribed antibiotics. What should the nurse inform the client about antibiotic therapy?

Correct answer: D

Rationale: Completing the full course of antibiotics is crucial to fully eradicate the infection and prevent the development of antibiotic resistance. Informing the client about the importance of finishing the prescribed course helps in ensuring the effectiveness of the treatment and reduces the risk of recurrence. Choice A is incorrect because antibiotics do not generally interfere with oral contraceptive effectiveness. Choice B is incorrect because drowsiness is not a common side effect of antibiotics. Choice C is incorrect because while some antibiotics may need to be taken with meals, it is not a universal rule for all antibiotics.

4. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?

Correct answer: B

Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.

5. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

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