HESI LPN
Adult Health Exam 1
1. The nurse observes a client with new-onset tachycardia. What should the nurse do first?
- A. Check for the client's temperature
- B. Administer prescribed beta-blockers
- C. Assess for any chest pain or discomfort
- D. Monitor the client's blood pressure
Correct answer: C
Rationale: When a client presents with new-onset tachycardia, the first action the nurse should take is to assess for any associated symptoms like chest pain or discomfort. This is important to differentiate the potential causes of tachycardia and guide appropriate interventions. Checking the client's temperature (Choice A) may be relevant in certain situations but is not the priority when tachycardia is observed. Administering prescribed beta-blockers (Choice B) should only be done after a comprehensive assessment and healthcare provider's orders. Monitoring the client's blood pressure (Choice D) is important, but assessing for chest pain or discomfort takes precedence in this scenario to rule out cardiac causes of tachycardia.
2. A healthcare professional is teaching a class of new parents about how to position their infants during the first few weeks of life. Which position is safest?
- A. On the back, lying flat
- B. On either side, lying flat
- C. Head slightly elevated on the left side
- D. Head slightly elevated on the right side
Correct answer: A
Rationale: The correct answer is 'On the back, lying flat.' Placing infants on their back to sleep is recommended to reduce the risk of sudden infant death syndrome (SIDS). This position promotes safe sleep practices and helps prevent accidental suffocation. Choices B, C, and D are incorrect as placing infants on their side or with the head slightly elevated may increase the risk of breathing difficulties or other hazards during sleep.
3. While a client is receiving the medication haloperidol, which client data would indicate to the practical nurse that the medication is therapeutic?
- A. The client has maintained consistent weight loss of 2 pounds per week.
- B. The client has demonstrated a decrease in paranoid behaviors.
- C. The client's blood pressure has remained within normal limits.
- D. The client's fasting blood glucose has remained below 120 mg/dL.
Correct answer: B
Rationale: When a client is taking haloperidol, a therapeutic response involves a decrease in symptoms such as paranoia, hallucinations, delusions, and emotional excitement. These improvements indicate that the medication is effectively managing the client's condition. Monitoring for a reduction in paranoid behaviors helps the practical nurse assess the medication's effectiveness in addressing the client's psychiatric symptoms.
4. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic
- B. Obtain current client data to compare with expected outcomes
- C. Modify the nursing interventions to achieve the client's goals
- D. Review related professional standards of care
Correct answer: B
Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.
5. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?
- A. 107 mL/hr.
- B. 107 mL/hr.
- C. 107 mL/hr.
- D. 107 mL/hr.
Correct answer: A
Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.