HESI LPN
Adult Health 1 Final Exam
1. What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag daily
- B. Irrigate the colostomy daily
- C. Avoid high-fiber foods
- D. Assess the stoma for color and swelling
Correct answer: D
Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.
2. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?
- A. Take the medication with food.
- B. Expect to see improvement within 24 hours.
- C. Avoid drinking grapefruit juice.
- D. Report any thoughts of self-harm immediately.
Correct answer: D
Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.
3. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?
- A. Encourage increased oral fluids.
- B. Provide high-protein snacks.
- C. Change the wound dressing.
- D. Administer prescribed antibiotics.
Correct answer: D
Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.
4. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
- A. Filtration
- B. Diffusion
- C. Osmosis
- D. Active transport
Correct answer: C
Rationale: The correct answer is C: Osmosis. Osmosis is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space to maintain cellular balance. In osmosis, water moves across a semi-permeable membrane from an area of low solute concentration (hypotonic) to an area of high solute concentration (hypertonic). This process helps regulate the water content inside cells. Choices A, B, and D are incorrect. Filtration involves the movement of solutes and solvents through a membrane due to a pressure difference, diffusion is the movement of solutes from an area of high concentration to low concentration, and active transport requires energy to move substances against their concentration gradient.
5. A nurse in a pediatric unit is preparing to administer medication to a child. What should the nurse do to ensure the correct dosage?
- A. Check the child's weight
- B. Verify the medication order with a pharmacist
- C. Consult the child's parents
- D. Double-check the dosage calculations with another nurse
Correct answer: D
Rationale: When administering medication to children, it is crucial to ensure the correct dosage to prevent dosing errors. Double-checking the dosage calculations with another nurse can help verify the accuracy of the prescribed dose, reducing the risk of medication errors. While checking the child's weight (Choice A) is important for dosage calculation, it alone may not ensure the correctness of the dosage. Verifying the medication order with a pharmacist (Choice B) is essential, but it may not directly address the accuracy of dosage calculations. Consulting the child's parents (Choice C) is not a standard practice for verifying medication dosages and should not be solely relied upon for ensuring the correct dosage.
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