HESI LPN
Adult Health 2 Exam 1
1. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?
- A. Administer insulin as prescribed
- B. Provide a carbohydrate-controlled snack
- C. Encourage physical activity
- D. Recheck the blood sugar
Correct answer: A
Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.
2. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?
- A. Deltoid muscle
- B. Dorsogluteal muscle
- C. Ventrogluteal muscle
- D. Abdomen
Correct answer: D
Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.
3. The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous
- A. 1,2,3,4
- B. 4,3,2,1
- C. 2,4,3,1
- D. 3,4,1,2
Correct answer: A
Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.
4. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?
- A. Stand the client to void and run tap water within hearing distance before catheterizing
- B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
- C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
- D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon
Correct answer: D
Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.
5. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?
- A. Appetite
- B. Mood
- C. Withdrawal
- D. Energy level
Correct answer: B
Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.
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