HESI LPN
Adult Health 2 Exam 1
1. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?
- A. Compartment syndrome
- B. Deep vein thrombosis
- C. Wound infection
- D. All of the above
Correct answer: A
Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.
2. 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.
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. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
- A. Abnormal skin color changes in a client with dark skin cannot be determined
- B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
- C. The lips and mucus membranes of a client with dark skin are dusky in color
- D. Cyanosis in a client with dark skin is seen in the sclera
Correct answer: C
Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.
5. 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.
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