HESI LPN
Adult Health 2 Exam 1
1. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?
- A. Phenytoin level
- B. Sodium level
- C. Hemoglobin level
- D. White blood cell count
Correct answer: A
Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.
2. A prenatal educator is teaching a class about false labor. Which of the following information should the educator include?
- A. Contractions will become more intense with walking
- B. There will be dilation and effacement of the cervix
- C. There will be bloody show
- D. Contractions will become temporarily regular
Correct answer: D
Rationale: The correct answer is D. False labor contractions, also known as Braxton Hicks contractions, are typically irregular and do not lead to cervical dilation or effacement. They are often described as sporadic and temporary, becoming temporarily regular. Choices A, B, and C are incorrect because false labor contractions do not intensify with activity, do not cause cervical changes like dilation and effacement, and are not associated with the presence of a bloody show.
3. In which position will you place your patient when they are demonstrating the signs and symptoms of hypovolemic shock?
- A. The Trendelenburg position
- B. The supine position
- C. The left lateral position
- D. The right lateral position
Correct answer: A
Rationale: The correct answer is A, the Trendelenburg position. This position involves placing the patient with their legs elevated higher than their head. It is used to increase blood flow to the upper body, including the brain and heart, in cases of hypovolemic shock. This helps improve perfusion to vital organs. Choices B, C, and D are incorrect as they do not facilitate the desired redistribution of blood flow needed in hypovolemic shock. The supine position is lying flat on the back, the left lateral position is lying on the left side, and the right lateral position is lying on the right side.
4. A client with chronic kidney disease is prescribed sevelamer carbonate. The nurse should monitor for which potential side effect?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct answer: A
Rationale: When a client with chronic kidney disease is prescribed sevelamer carbonate, the nurse should monitor for hypercalcemia as a potential side effect. Sevelamer carbonate can bind to dietary calcium and impair its absorption, potentially leading to elevated calcium levels in the blood. Monitoring calcium levels is crucial to detect and manage hypercalcemia promptly. Hypocalcemia (choice B) is incorrect because sevelamer carbonate's action is more likely to cause elevated calcium levels. Hyperkalemia (choice C) and hypokalemia (choice D) are related to potassium levels and are not typically associated with sevelamer carbonate use.
5. A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant’s body should the nurse assess?
- A. Rectum
- B. Nasopharynx
- C. Intestinal tract
- D. Laryngopharynx
Correct answer: B
Rationale: Choanal atresia is a congenital condition that presents with a blockage in the nasal passages at the junction of the nasal cavity and the nasopharynx. To assess and confirm the diagnosis of choanal atresia, the nurse should focus on assessing the nasopharynx. Choices A, C, and D are incorrect as choanal atresia specifically involves a blockage in the nasal passages, not the rectum, intestinal tract, or laryngopharynx. By assessing the nasopharynx, the severity of the obstruction can be determined, aiding in planning appropriate interventions for the newborn.