HESI LPN
Adult Health 1 Final Exam
1. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?
- A. Measure the amount of a client's residual urine after voiding
- B. Cleanse the perineal area of a client with urinary incontinence
- C. Insert a straight catheter to obtain a urine specimen for culture
- D. Provide catheter care for a client with a suprapubic catheter
Correct answer: B
Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.
2. A client is prescribed metformin for the management of type 2 diabetes. What is the primary action of this medication?
- A. Stimulates insulin secretion from the pancreas.
- B. Increases insulin sensitivity in various tissues.
- C. Decreases hepatic glucose production.
- D. Delays absorption of glucose from the intestines.
Correct answer: C
Rationale: The correct answer is C: Decreases hepatic glucose production. Metformin primarily works by reducing the production of glucose in the liver (hepatic glucose production) and by improving insulin sensitivity in various tissues. Choice A is incorrect as metformin does not stimulate insulin secretion from the pancreas. Choice B is incorrect as metformin increases insulin sensitivity in various tissues, not just muscle cells. Choice D is incorrect as metformin does not delay glucose absorption from the intestines.
3. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?
- A. Turns from side to back and returns
- B. Consistently returns smiles to mother
- C. Finds hands and plays with fingers
- D. Holds head up and supports weight with arms
Correct answer: B
Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.
4. When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?
- A. Slightly above the level of the heart
- B. At the level of the heart
- C. At a level of comfort for the client
- D. Below the level of the heart
Correct answer: B
Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.
5. The client has chronic renal failure. What dietary modification is most important for this client?
- A. Increase protein intake
- B. Limit potassium-rich foods
- C. Increase sodium intake
- D. Encourage dairy products
Correct answer: B
Rationale: Limiting potassium-rich foods is crucial in chronic renal failure to prevent hyperkalemia, which can lead to cardiac complications. Excessive protein intake can increase the workload on the kidneys and may result in the accumulation of uremic toxins. Increasing sodium intake is generally discouraged in chronic renal failure due to its association with hypertension and fluid retention. Encouraging dairy products may not be suitable for all clients with chronic renal failure, as they are a significant source of phosphorus, which needs to be limited in renal failure to prevent mineral imbalances.
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