HESI LPN
Adult Health Exam 1 Chamberlain
1. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?
- A. Use sterile technique for catheter care
- B. Ensure the catheter bag is below the level of the bladder
- C. Provide perineal care daily
- D. Change the catheter only when necessary
Correct answer: B
Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.
2. What are the final factors that contribute to blood pressure? (Select all that apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct answer: D
Rationale: Neuroendocrine hormones play a crucial role in regulating blood pressure by influencing factors like fluid balance, blood volume, and vessel constriction. While heart rate, stroke volume, and peripheral resistance are important factors affecting blood pressure, the final parameters that directly produce blood pressure are influenced by neuroendocrine hormones. Therefore, choice D is the correct answer. Choices A, B, and C are involved in the regulation of blood pressure but are not the final parameters that directly produce it.
3. A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach
- B. Monitor sodium intake
- C. Report any signs of weight gain
- D. Avoid excessive caffeine intake
Correct answer: B
Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.
4. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?
- A. Recheck the radial pulse in thirty minutes
- B. Palpate the radial pulse for thirty seconds and double the rate
- C. Count the apical pulse rate for sixty seconds
- D. Compare the radial pulse rate bilaterally and record the higher rate
Correct answer: C
Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.
5. The healthcare provider is preparing to administer an IM injection to an adult client. Which site is the preferred location for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Ventrogluteal muscle
- D. Dorsogluteal muscle
Correct answer: C
Rationale: The ventrogluteal site is the preferred site for IM injections in adults due to its muscle mass and low risk of nerve injury. The deltoid muscle, although commonly used for vaccines in adults due to easy accessibility, has a smaller muscle mass making it less ideal for IM injections. The vastus lateralis muscle is typically used in infants and young children, not in adults. The dorsogluteal site has a higher risk of injury to the sciatic nerve and is no longer recommended for IM injections in any age group.
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