HESI LPN
Adult Health Exam 1
1. A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?
- A. Administer morphine for pain relief
- B. Encourage the client to perform isometric exercises
- C. Position the client flat in bed
- D. Restrict fluid intake
Correct answer: A
Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.
2. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?
- A. Check the client’s blood type compatibility
- B. Monitor the client for signs of transfusion reaction
- C. Verify the correct client and blood product with another healthcare professional
- D. All of the above
Correct answer: D
Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.
3. The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Dorsogluteal muscle
- D. Vastus lateralis muscle
Correct answer: D
Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in infants due to its size and safety. The deltoid muscle is typically used for adults and older children. The ventrogluteal muscle is more commonly used in toddlers and older children. The dorsogluteal muscle is not recommended for intramuscular injections in any age group due to its proximity to major nerves and blood vessels, which poses a risk of injury or sciatic nerve damage.
4. The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?
- A. Ensure continuous bubbling in the water seal chamber
- B. Measure the amount of drainage every shift
- C. Keep the drainage system at the level of the chest
- D. Assess for subcutaneous emphysema around the insertion site
Correct answer: D
Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.
5. When caring for a client with a tracheostomy, what is the most important assessment to perform?
- A. Check the client's oxygen saturation
- B. Assess the tracheostomy site for signs of infection
- C. Monitor the client's respiratory rate
- D. Ensure the tracheostomy ties are secure
Correct answer: A
Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.
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