HESI LPN
Adult Health 2 Exam 1
1. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?
- A. Administer insulin as prescribed
- B. Provide a carbohydrate-controlled snack
- C. Encourage physical activity
- D. Recheck the blood sugar
Correct answer: A
Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.
2. The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?
- A. I will change my colostomy bag every day.
- B. I should eat a low-fiber diet.
- C. I need to inspect the stoma daily for color and swelling.
- D. I can skip my colostomy care if I feel well.
Correct answer: C
Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.
3. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?
- A. Schedule a follow-up appointment
- B. Start making immediate dietary changes
- C. Begin an exercise program
- D. All of the above
Correct answer: A
Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.
4. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
5. Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who
- A. is immobile on prescribed bedrest.
- B. has pressure ulcers on several toes.
- C. has diminished pedal pulse volume.
- D. is confused and trying to climb out of bed.
Correct answer: A
Rationale: The correct answer is A. Pneumatic compression devices are most beneficial for immobile clients on prescribed bedrest to prevent deep vein thrombosis. Applying these devices helps in promoting circulation and preventing blood clots. Choices B, C, and D do not specifically relate to the primary indication for pneumatic compression devices, making them incorrect. Pressure ulcers, diminished pedal pulse volume, and confusion with climbing out of bed may require different interventions or treatments.
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