which organ lays retroperitoneally
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. Which organ lies retroperitoneally?

Correct answer: A

Rationale: The correct answer is A: Kidneys. The kidneys are located retroperitoneally, behind the peritoneum, providing structural protection and maintaining a stable position within the abdominal cavity. This location helps protect them from external physical trauma. Choices B, C, and D are incorrect because testicles, urinary bladder, and pancreas are not located retroperitoneally. Testicles are located in the scrotum, the urinary bladder is located in the pelvis, and the pancreas is located in the upper abdomen, not retroperitoneally.

2. A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)

Correct answer: A

Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.

3. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

4. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?

Correct answer: D

Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.

5. A client with a history of hypertension is prescribed lisinopril. Which potential side effect should the nurse monitor for?

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Lisinopril is an ACE inhibitor commonly associated with a persistent dry cough as a side effect. This cough is thought to result from increased bradykinin levels. Choices A, B, and D are incorrect. Hypokalemia is not a common side effect of lisinopril; in fact, it may lead to hyperkalemia. Hyperglycemia is not a typical side effect of lisinopril use. Tachycardia is also not a common side effect associated with ACE inhibitors like lisinopril.

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