HESI LPN
Adult Health 2 Exam 1
1. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
- A. Filtration
- B. Diffusion
- C. Osmosis
- D. Active transport
Correct answer: C
Rationale: The correct answer is C: Osmosis. Osmosis is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space to maintain cellular balance. In osmosis, water moves across a semi-permeable membrane from an area of low solute concentration (hypotonic) to an area of high solute concentration (hypertonic). This process helps regulate the water content inside cells. Choices A, B, and D are incorrect. Filtration involves the movement of solutes and solvents through a membrane due to a pressure difference, diffusion is the movement of solutes from an area of high concentration to low concentration, and active transport requires energy to move substances against their concentration gradient.
2. A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?
- A. Daily weight
- B. Electrolyte levels
- C. Urine output
- D. All of the above
Correct answer: D
Rationale: Monitoring daily weight, electrolyte levels, and urine output is crucial in evaluating treatment effectiveness for heart failure. Daily weight monitoring helps assess fluid retention or loss, changes in electrolyte levels can indicate imbalances affecting heart function, and urine output monitoring provides insights into kidney function and fluid balance. Therefore, all options are essential components in assessing the patient's fluid status and response to treatment, making 'All of the above' the correct answer. Choices A, B, and C are incorrect individually as they only represent partial aspects of monitoring heart failure treatment effectiveness.
3. During the assessment of a client who has suffered a stroke, what finding would indicate a complication?
- A. Difficulty swallowing
- B. A slight headache
- C. High blood pressure
- D. Muscle weakness on one side
Correct answer: A
Rationale: Difficulty swallowing (dysphagia) can indicate complications such as aspiration risk, which is common after a stroke due to impaired swallowing reflexes. It poses a serious threat to the client's respiratory system. Options B, C, and D are less likely to indicate immediate complications post-stroke. A slight headache is a common complaint and may not necessarily indicate a complication. High blood pressure is a known risk factor for strokes but may not be an immediate post-stroke complication unless it is severely elevated. Muscle weakness on one side is a common sign of stroke but may not directly indicate a new complication.
4. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?
- A. Advise the client that suctioning will be used to obtain another specimen
- B. Re-instruct the client in coughing techniques to obtain another specimen
- C. Provide the client a glass of water and mouthwash to rinse the mouth
- D. Label the container and place the container in a biohazard transport bag
Correct answer: C
Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.
5. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
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