HESI LPN
Adult Health 2 Final Exam
1. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?
- A. Apply an ice pack
- B. Document the findings and monitor
- C. Notify the surgeon
- D. Clean the wound with sterile saline
Correct answer: C
Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.
2. A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?
- A. Tobacco use.
- B. Folic acid deficiency.
- C. Short interval between pregnancies.
- D. Preeclampsia.
Correct answer: B
Rationale: Folic acid deficiency during pregnancy is strongly associated with neural tube defects like spina bifida occulta. Adequate folic acid intake before and during early pregnancy significantly reduces the risk of such complications. Tobacco use (Choice A) is linked to other adverse outcomes but not specifically spina bifida occulta. Short intervals between pregnancies (Choice C) can increase the risk of preterm birth and low birth weight but are not directly linked to spina bifida occulta. Preeclampsia (Choice D) is a hypertensive disorder that poses risks to both the mother and baby but is not the primary factor contributing to spina bifida occulta development.
3. What is a key preventive measure for avoiding urinary tract infections (UTIs) in children?
- A. Restrict fluid intake
- B. Encourage frequent urination
- C. Use topical antibiotics
- D. Increase dietary calcium
Correct answer: B
Rationale: Encouraging frequent urination is a key preventive measure for avoiding urinary tract infections (UTIs) in children. It helps flush bacteria from the urinary tract, reducing the risk of UTIs. Restricting fluid intake (Choice A) is not recommended as it may lead to concentrated urine and increase the risk of UTIs. Using topical antibiotics (Choice C) is not a preventive measure for UTIs and should only be used under medical guidance. Increasing dietary calcium (Choice D) is not directly linked to preventing UTIs in children.
4. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?
- A. Observe the appearance of the stool
- B. Assess the client’s skin turgor
- C. Review the client’s laboratory values
- D. Auscultate the client’s bowel sounds
Correct answer: A
Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.
5. A client is prescribed diazepam for muscle spasms. What instruction should the nurse include in the client's teaching plan?
- A. Avoid drinking alcohol
- B. Take with food to avoid gastrointestinal upset
- C. Increase fluid intake
- D. Take medication with grapefruit juice
Correct answer: A
Rationale: The correct instruction for a client prescribed diazepam for muscle spasms is to avoid drinking alcohol. Diazepam can cause drowsiness and enhance the effects of alcohol, leading to increased sedation and impaired cognitive function. Clients should be advised to avoid alcohol consumption while taking diazepam to prevent these adverse effects and ensure their safety.