HESI LPN
Adult Health 1 Final Exam
1. The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow down the rate of the transfusion
- B. Administer an antipyretic
- C. Stop the transfusion immediately
- D. Notify the healthcare provider
Correct answer: C
Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.
2. When should discharge planning be initiated for a client experiencing an exacerbation of heart failure?
- A. During the admission process.
- B. After the client stabilizes.
- C. Only after the client requests it.
- D. At the time of discharge.
Correct answer: A
Rationale: Discharge planning should begin during the admission process for a client experiencing an exacerbation of heart failure. Initiating discharge planning early ensures timely and effective care transitions, which are crucial for managing the client's condition and preventing readmissions. Waiting until after the client stabilizes (choice B) could lead to delays in arranging necessary follow-up care and support services. Similarly, waiting for the client to request discharge planning (choice C) may result in missed opportunities for comprehensive care coordination. Planning at the time of discharge (choice D) is too late, as early intervention is key to promoting the client's well-being and recovery in the long term.
3. A nurse is caring for a client who has herpes zoster. The client asks about complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Acupuncture
- B. Massage therapy
- C. Aromatherapy
- D. Herbal supplements
Correct answer: A
Rationale: The correct answer is A, Acupuncture. Acupuncture is contraindicated for clients with herpes zoster due to the risk of infection at the needle sites. In individuals with herpes zoster, the skin's integrity is compromised, increasing susceptibility to infections. Therefore, acupuncture, which involves inserting needles into the skin, can introduce pathogens and lead to local infections. Massage therapy (B), aromatherapy (C), and herbal supplements (D) do not involve skin penetration like acupuncture and are generally considered safe complementary therapies for pain control in clients with herpes zoster.
4. A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority?
- A. “We just don’t understand why our child can’t keep up with the other kids in simple activities like running and jumping.”
- B. “Our child keeps trying to find ways around our household rules. They always want to make deals with us.”
- C. “We think our child is trying too hard to excel in math just to get the top grades in the class.”
- D. “Our child likes to sing and worries it will make the other kids want to laugh.”
Correct answer: A
Rationale: The correct answer is A. Difficulty in keeping up with physical activities like running and jumping may indicate an underlying physical or developmental issue that requires prompt assessment. This could be related to musculoskeletal problems, coordination difficulties, or other health concerns that need further evaluation. Choices B, C, and D, while important, do not address a potential physical or developmental issue that could impact the child's overall well-being. Addressing the child's physical limitations should be the priority to ensure appropriate support and intervention.
5. A client with type 2 diabetes is prescribed metformin. What instruction should the practical nurse (PN) include in the client's teaching plan?
- A. Take the medication with meals to decrease gastrointestinal upset.
- B. Take the medication with a full glass of water.
- C. Avoid alcohol while taking the medication.
- D. Take the medication with meals to increase absorption.
Correct answer: B
Rationale: The correct instruction for a client prescribed metformin is to take the medication with a full glass of water. This helps ensure proper ingestion and absorption of the medication. While taking metformin with meals can help reduce gastrointestinal side effects, the primary focus should be on adequate hydration and absorption by taking it with water. Avoiding alcohol while taking metformin is also important as alcohol can increase the risk of lactic acidosis when combined with metformin. Taking the medication with meals to increase absorption is incorrect as metformin should be taken with food to reduce gastrointestinal upset, not to increase absorption.