HESI LPN
Adult Health 2 Exam 1
1. Which organ lies retroperitoneally?
- A. Kidneys
- B. Testicles
- C. Urinary bladder
- D. Pancreas
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 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.
3. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?
- A. Bed rest with bathroom privileges only
- B. Frequent, short walks with assistance
- C. Range of motion exercises to the knee every four hours
- D. Leg elevation to reduce swelling
Correct answer: B
Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.
4. The healthcare provider is assessing a client with a suspected diagnosis of appendicitis. Which symptom is most indicative of this condition?
- A. Right upper quadrant pain
- B. Nausea and vomiting
- C. Rebound tenderness at McBurney's point
- D. Hematuria
Correct answer: C
Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This symptom is due to irritation of the peritoneum when pressure is released during palpation. Right upper quadrant pain (Choice A) is more commonly associated with gallbladder issues. Nausea and vomiting (Choice B) can occur in various abdominal conditions and are not specific to appendicitis. Hematuria (Choice D) is the presence of blood in the urine and is not a typical symptom of appendicitis.
5. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?
- A. The solution's rate is too rapid
- B. The client has phlebitis
- C. The infusion site is infected
- D. The infusion is infiltrated
Correct answer: D
Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.
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