HESI LPN
Adult Health Exam 1 Chamberlain
1. What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag only when necessary
- B. Eat a low-residue diet
- C. Assess the stoma for color and swelling
- D. Irrigate the colostomy only if advised by a healthcare provider
Correct answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.
2. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?
- A. Administer insulin as prescribed
- B. Provide a carbohydrate-controlled snack
- C. Encourage physical activity
- D. Recheck the blood sugar
Correct answer: A
Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.
3. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?
- A. Application of topical antibacterial cream
- B. Use of careful hand washing technique
- C. Administration of plasma expanders
- D. Limiting visitors to the burned client
Correct answer: B
Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.
4. What is the function of the cervix in reproduction?
- A. Accepts and interprets signals of sexual stimuli
- B. Secretes mucus to facilitate sperm transport
- C. Serves as the site for union of ovum and sperm
- D. Receives the penis during intercourse
Correct answer: B
Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.
5. When reconstituted, how many milligrams are in each milliliter of solution?
- A. 300 mg/mL
- B. 350 mg/mL
- C. 450 mg/mL
- D. 400 mg/mL
Correct answer: D
Rationale: After reconstitution, the concentration of the cefazolin solution is 400 mg/mL. This calculation is derived by dividing the total milligrams in the vial (1000 mg) by the total volume after reconstitution (2.5 mL). Therefore, each milliliter of the solution contains 400 mg of cefazolin. Choices A, B, and C are incorrect as they do not match the correct calculation based on the information provided.
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