HESI LPN
Adult Health 2 Exam 1
1. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?
- A. Restrict sodium intake
- B. Encourage high-protein meals
- C. Increase fluid intake
- D. Administer diuretics as prescribed
Correct answer: D
Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.
2. The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse’s priority action?
- A. Slow the rate of infusion
- B. Apply a warm compress to the site
- C. Discontinue the IV infusion
- D. Elevate the affected arm
Correct answer: C
Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.
3. Which structures are located in the subcutaneous layer of the skin?
- A. Sebaceous and sweat glands
- B. Melanin and keratin
- C. Sensory receptors and hair follicles
- D. Adipose cells and blood vessels
Correct answer: D
Rationale: The correct answer is D: Adipose cells and blood vessels. The subcutaneous layer, also known as the hypodermis, primarily consists of adipose (fat) tissue and blood vessels. Adipose tissue provides insulation, energy storage, and cushioning, while blood vessels supply nutrients and oxygen. Sebaceous and sweat glands are located in the dermis, which is the layer beneath the epidermis. Melanin and keratin are components of the epidermis, responsible for skin color and waterproofing, respectively. Sensory receptors and hair follicles are found in the dermis and extend into the subcutaneous layer but are not exclusive to it.
4. The nurse is monitoring a client who started taking a new medication for rheumatoid arthritis. What is the most important aspect to monitor?
- A. Signs of gastrointestinal bleeding
- B. Liver function tests
- C. Renal function tests
- D. All necessary monitoring based on the medication prescribed
Correct answer: D
Rationale: When a client starts a new medication for rheumatoid arthritis, it is crucial to monitor all necessary aspects based on the specific medication prescribed. Different medications can have varying side effects and impacts on different organ systems. Monitoring all relevant parameters ensures the early detection of any adverse effects and helps to maintain the client's safety. While monitoring for signs of gastrointestinal bleeding, liver function tests, and renal function tests are all important in certain situations, the priority is to conduct comprehensive monitoring based on the medication's known effects.
5. The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. ''I will inspect my feet daily for any cuts or blisters.''
- B. ''I will soak my feet in warm water every day.''
- C. ''I will wear shoes that fit properly to avoid injury.''
- D. ''I will avoid walking barefoot to protect my feet.''
Correct answer: B
Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.
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