HESI LPN
Adult Health 2 Exam 1
1. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?
- A. Signs of infection to monitor for
- B. Pain management techniques
- C. Activity restrictions and safety measures
- D. All of the above
Correct answer: D
Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.
2. A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?
- A. Hemoglobin 9.5 g/dL
- B. Potassium 6.2 mEq/L
- C. Creatinine 3.5 mg/dL
- D. BUN 50 mg/dL
Correct answer: B
Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.
3. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?
- A. The solution's rate is too rapid
- B. The client has phlebitis
- C. The infusion site is infected
- D. The infusion is infiltrated
Correct answer: D
Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.
4. 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.
5. 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.
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