HESI LPN
Adult Health 2 Exam 1
1. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?
- A. Restrict sodium intake
- B. Encourage high-protein meals
- C. Increase fluid intake
- D. Administer diuretics as prescribed
Correct answer: D
Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.
2. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken?
- A. Most infants have slow respirations when they are uncomfortable.
- B. The respiratory rates of young infants are irregular, so a drop in rate is unimportant.
- C. Vital signs that are outside the expected parameters are significant and should be documented.
- D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.
Correct answer: C
Rationale: In this scenario, the nurse failed to report or document the slow respiratory rate of the infant, which later led to severe respiratory distress. It is crucial to understand that any vital signs outside the expected range in an infant should be documented and reported promptly. This documentation is vital for monitoring the infant's condition, identifying potential issues, and ensuring timely intervention if needed. Choices A, B, and D are incorrect because they downplay the significance of abnormal vital signs and fail to emphasize the importance of documentation and reporting in infant care.
3. When a patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium, the nurse should monitor for potential side effects. The correct answer is dry mouth. Ipratropium can cause dry mouth as a common side effect due to its anticholinergic effects. This side effect can impact the patient's oral health and comfort, requiring close monitoring and appropriate interventions.
- A. Dry mouth
- B. Tachycardia
- C. Insomnia
- D. Increased appetite
Correct answer: A
Rationale: Ipratropium is an anticholinergic medication commonly used in COPD. One of the most common side effects of anticholinergics is dry mouth due to the inhibition of salivary gland function. Tachycardia (Choice B) is not a typical side effect of ipratropium. Insomnia (Choice C) is also not a common side effect of this medication. Increased appetite (Choice D) is not associated with ipratropium use. Therefore, the correct side effect to monitor for in a patient prescribed ipratropium is dry mouth.
4. Which bioterrorism agent poses a high risk for use as a potential biological weapon due to its ability to be readily transmitted through several portals of entry?
- A. Anthrax.
- B. Smallpox.
- C. Botulism.
- D. Tularemia.
Correct answer: A
Rationale: The correct answer is Anthrax. Anthrax is a high-risk bioterrorism agent because it can be readily transmitted through multiple portals of entry such as inhalation, ingestion, or skin contact. This makes it a significant concern for use as a biological weapon. Smallpox, though highly contagious, is not known for multiple portals of entry like Anthrax. Botulism is a potent toxin but is not as easily transmissible through various routes as Anthrax. Tularemia, while a serious bacterial infection, does not have the same ease of transmission through multiple portals of entry as Anthrax.
5. When a mother confides in the nurse that she is contemplating divorce, which suggestion by the nurse would help minimize the effects on the child?
- A. Tell the child together using appropriate terms.
- B. Reassure the child that no one loves him more than his parents.
- C. Engage in special activities with the child to compensate for the divorce.
- D. Discuss your feelings with the child.
Correct answer: A
Rationale: The correct answer is A. It is essential for both parents to inform the child about the divorce together, using age-appropriate language. This approach can help minimize the negative impact on the child by providing a sense of unity and understanding. Choice B is incorrect because offering false reassurance about love may not address the child's concerns effectively, as the situation is complex. Choice C is not suitable as engaging in special activities cannot substitute for the emotional stability that the child may lose due to the divorce. Choice D is incorrect because sharing the parent's feelings may burden the child with adult emotions, which could be overwhelming and confusing for their developmental stage.