HESI LPN
Adult Health 2 Exam 1
1. 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.
2. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?
- A. Check blood pressure
- B. Assess heart rate
- C. Monitor respiratory rate
- D. Measure oxygen saturation
Correct answer: B
Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.
3. The healthcare provider reviews the laboratory results of a client whose serum pH is 7.38. What does this value imply about the client's homeostasis?
- A. Alkalosis
- B. Acidosis
- C. Normal serum pH
- D. Incompatible with life
Correct answer: C
Rationale: A pH of 7.38 falls within the normal range (7.35-7.45), indicating that the client’s acid-base balance is adequately maintained. Choices A and B are incorrect as alkalosis and acidosis refer to abnormal pH levels. Choice D is incorrect as a pH of 7.38 within the normal range is compatible with life.
4. After delivering a healthy newborn, a client is experiencing postpartum hemorrhage. What initial intervention should the nurse implement?
- A. Administer IV fluids
- B. Perform a uterine massage
- C. Monitor the newborn's vital signs
- D. Notify the healthcare provider
Correct answer: B
Rationale: The correct initial intervention for postpartum hemorrhage is to perform a uterine massage. This action helps the uterus contract, controlling bleeding. Administering IV fluids may be necessary but is not the initial intervention. Monitoring the newborn's vital signs is important but not the priority when managing postpartum hemorrhage. Notifying the healthcare provider can be done after initiating immediate interventions to address the hemorrhage.
5. The nurse is caring for a client with acute pancreatitis. Which intervention should be included in the plan of care?
- A. Provide a high-protein diet
- B. Encourage oral fluids
- C. Administer intravenous fluids as prescribed
- D. Monitor for signs of hyperglycemia
Correct answer: C
Rationale: The correct intervention to include in the plan of care for a client with acute pancreatitis is to administer intravenous fluids as prescribed. Intravenous fluids are crucial to maintain hydration and electrolyte balance in clients with acute pancreatitis. Providing a high-protein diet (Choice A) is not recommended initially for clients with acute pancreatitis, as they may need to be kept NPO (nothing by mouth) to rest the pancreas. Encouraging oral fluids (Choice B) may not be appropriate if the client is experiencing severe symptoms and requires intravenous fluids. Monitoring for signs of hyperglycemia (Choice D) is important but not the immediate intervention needed to address the fluid and electrolyte imbalances associated with acute pancreatitis.
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