HESI LPN
Adult Health 1 Final Exam
1. The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?
- A. Raise the bed to ensure the drainage bag remains off the floor
- B. Attach the drainage bag to the side rail instead of the bed frame
- C. Observe the appearance of the urine in the drainage tubing
- D. Secure the tubing to the client's gown instead of his abdomen
Correct answer: D
Rationale: The correct action for the nurse to implement is to secure the tubing to the client's gown instead of his abdomen. Securing the tubing to the client's abdomen can cause discomfort, trauma to the urethra, and increase the risk of infection. Attaching the drainage bag to the bed frame can lead to tension on the catheter, increasing the risk of dislodgement or trauma. Raising the bed does not address the issue of incorrect tubing securing. Observing the appearance of urine is important but secondary to ensuring proper tubing attachment.
2. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.
- A. Communicate expected behaviors to the client
- B. Ensure that the client knows that he or she is not in charge of the nursing unit
- C. Assist the client in identifying ways of setting limits on personal behaviors
- D. Follow through about the consequences of behavior in a non-punitive manner
Correct answer: B
Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.
3. During an oral cavity assessment of a 6-month-old infant, the parent inquires about which teeth will erupt first. How should the healthcare provider respond?
- A. Incisors
- B. Canines
- C. Upper molars
- D. Lower molars
Correct answer: A
Rationale: Incisors are the teeth that typically erupt first in infants, usually around 6 months of age. These teeth play a crucial role in biting and cutting food. Canines, upper molars, and lower molars are not the primary teeth to erupt in infants. Canines usually erupt after incisors, while molars, whether upper or lower, come in later during the teething process.
4. After eating, a child with a diagnosis of gastroesophageal reflux disease (GERD) should be placed in what position as recommended by the nurse?
- A. Supine
- B. Prone
- C. Semi-Fowler's
- D. Trendelenburg
Correct answer: C
Rationale: Placing the child in a semi-Fowler's position after eating is beneficial for reducing symptoms of gastroesophageal reflux. This position helps prevent gastric contents from flowing back into the esophagus. The supine position (choice A) may worsen reflux symptoms by allowing gravity to assist in reflux, leading to discomfort and regurgitation. Prone position (choice B) is not recommended after eating as it may cause discomfort and increase the risk of aspiration due to pressure on the stomach. Trendelenburg position (choice D), with the head lower than the rest of the body, is not indicated for managing GERD after eating and may not provide the desired benefits in this context.
5. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct answer: D
Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.