HESI LPN
Adult Health Exam 1
1. When caring for a client with a tracheostomy, what is the most important assessment to perform?
- A. Check the client's oxygen saturation
- B. Assess the tracheostomy site for signs of infection
- C. Monitor the client's respiratory rate
- D. Ensure the tracheostomy ties are secure
Correct answer: A
Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.
2. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?
- A. Remove the restraints every 4 hours.
- B. Attach the restraints securely to the side of the client's bed.
- C. Apply the restraints to allow as little movement as possible.
- D. Allow room for two fingers to fit between the client's skin and the restraints.
Correct answer: D
Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.
3. Why is peer review important in scientific research?
- A. To expedite publication of results.
- B. To facilitate the replication of studies.
- C. To verify the accuracy and validity of research findings.
- D. To enhance the credibility of the research.
Correct answer: C
Rationale: Peer review is crucial in scientific research to verify the accuracy and validity of research findings. By subjecting research papers to evaluation by experts in the field, peer review ensures that the study's methods, results, and conclusions are robust and reliable. This process helps to maintain high standards of quality in scientific publications, providing credibility to the research. Choices A and D are incorrect because the primary purpose of peer review is not to expedite publication or solely enhance credibility; its core function is to validate the research's accuracy and validity. Choice B, while beneficial, is not the primary reason for peer review; replication is a byproduct of the rigorous evaluation of research methods and findings.
4. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage VI
Correct answer: B
Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.
5. What is the first action to take before administering tube feeding to an infant?
- A. Irrigate the tube with water.
- B. Offer a pacifier to the infant.
- C. Slowly instill 10 mL of formula.
- D. Place the infant in the Trendelenburg position.
Correct answer: B
Rationale: The correct first action before administering tube feeding to an infant is to offer a pacifier. Providing a pacifier stimulates the sucking reflex, aiding in digestion and providing comfort to the infant. Irrigating the tube with water (Choice A) is not typically the initial step and could potentially introduce unnecessary fluid into the infant's system. Slowly instilling formula (Choice C) should only be done after ensuring the tube is appropriately placed. Placing the infant in the Trendelenburg position (Choice D) is not necessary for tube feeding and could pose risks such as aspiration.