HESI LPN
Adult Health 2 Exam 1
1. The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?
- A. Explain the benefits of ambulation for recovery
- B. Wait for the client to request to walk
- C. Tell the client that walking is necessary for discharge
- D. Offer pain medication before walking
Correct answer: A
Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.
2. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?
- A. Use short, simple sentences and maintain a calm demeanor
- B. Involve family members to provide reassurance
- C. Offer choices to empower the client
- D. All of the above
Correct answer: D
Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.
3. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.
4. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
- A. Temperature of 100.8°F
- B. A pulse rate of 150 beats per minute
- C. A respiratory rate of 10 breaths per minute
- D. A blood pressure of 180/110
Correct answer: C
Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.
5. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?
- A. Administer antibiotics as prescribed
- B. Perform chest physiotherapy
- C. Encourage increased fluid intake
- D. Provide humidified oxygen
Correct answer: C
Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.
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