HESI LPN
Adult Health 2 Exam 1
1. What is the primary function of neutrophils?
- A. Heparin secretion
- B. Transport oxygen
- C. Phagocytotic action
- D. Antibody formation
Correct answer: C
Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.
2. The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?
- A. The child looks at the floor when answering the nurse's questions
- B. The mother's version of the injury is different from the child's version
- C. The child has several abrasions on the chest and legs
- D. The mother refuses to answer questions about family history
Correct answer: B
Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.
3. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?
- A. Take your insulin as usual
- B. Do not eat or drink after midnight
- C. Monitor your blood glucose closely
- D. Bring your glucose meter to the hospital
Correct answer: B
Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.
4. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?
- A. Bilateral leg swelling.
- B. Sudden onset of chest pain.
- C. Gradual onset of dyspnea.
- D. Decreased breath sounds on auscultation.
Correct answer: C
Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.
5. 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.
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