HESI LPN
Adult Health 2 Exam 1
1. A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly.
- B. Provide a complex carbohydrate snack.
- C. Administer 50% dextrose intravenously.
- D. Give 15 grams of a fast-acting carbohydrate.
Correct answer: D
Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.
2. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?
- A. Phenytoin level
- B. Sodium level
- C. Hemoglobin level
- D. White blood cell count
Correct answer: A
Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.
3. 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.
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. A client with a urinary tract infection is prescribed antibiotics. What should the nurse inform the client about antibiotic therapy?
- A. It may interfere with oral contraceptive effectiveness
- B. It can cause drowsiness
- C. It should be taken with meals
- D. Completing the full course is crucial
Correct answer: D
Rationale: Completing the full course of antibiotics is crucial to fully eradicate the infection and prevent the development of antibiotic resistance. Informing the client about the importance of finishing the prescribed course helps in ensuring the effectiveness of the treatment and reduces the risk of recurrence. Choice A is incorrect because antibiotics do not generally interfere with oral contraceptive effectiveness. Choice B is incorrect because drowsiness is not a common side effect of antibiotics. Choice C is incorrect because while some antibiotics may need to be taken with meals, it is not a universal rule for all antibiotics.
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