HESI LPN
Adult Health 1 Final Exam
1. The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?
- A. Monitor bowel sounds
- B. Provide frequent oral care
- C. Encourage ambulation
- D. Measure abdominal girth
Correct answer: B
Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.
2. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?
- A. Encourage mobilization and ambulation
- B. Encourage energy conservation with complete bed rest
- C. Provide humidified oxygen via nasal cannula
- D. Restrict oral (PO) and intravenous fluids
Correct answer: A
Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.
3. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?
- A. Hoarseness of the voice
- B. Slight swelling at the incision site
- C. Tingling around the mouth
- D. Mild fever
Correct answer: C
Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.
4. The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?
- A. Increase the intake of spicy foods
- B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Drink coffee in moderation
- D. Eat large meals at bedtime
Correct answer: B
Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated
- B. Avoid wearing oxygen during physical activity
- C. Do not smoke while using oxygen
- D. Store oxygen tanks in a cool, dark place
Correct answer: C
Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.
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