HESI LPN
Adult Health 2 Exam 1
1. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
2. A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?
- A. Take the medication at bedtime.
- B. Monitor drug levels regularly.
- C. Avoid alcohol while taking this medication.
- D. Take the medication at the same time every day.
Correct answer: B
Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.
3. The nurse is caring for a postoperative client who is reluctant to ambulate. What strategy should the nurse use to encourage the client?
- A. Explain the benefits of ambulation for recovery
- B. Wait for the client to request to walk
- C. Tell the client that walking is necessary for discharge
- D. Offer pain medication before walking
Correct answer: A
Rationale: Corrected Rationale: The correct strategy for the nurse to encourage the postoperative client to ambulate is to explain the benefits of ambulation for recovery. Educating the client on how ambulation aids in preventing complications and promotes faster recovery can motivate their participation. Choice B is incorrect because waiting for the client to request to walk may lead to delays in mobilization. Choice C is incorrect as it may induce unnecessary fear in the client. Choice D is incorrect as offering pain medication before walking does not address the client's reluctance to ambulate.
4. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?
- A. Perform hand hygiene before and after handling the catheter
- B. Change the catheter every 72 hours
- C. Apply antibiotic ointment at the insertion site
- D. Irrigate the catheter daily
Correct answer: A
Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.
5. A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.
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