HESI LPN
Adult Health Exam 1
1. A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?
- A. Conversion of irregular heart rate to regular heart rhythm
- B. Pulse oximetry readings within normal range during activity
- C. Peripheral pulse points with adequate capillary refill
- D. Increase in exercise tolerance without shortness of breath
Correct answer: A
Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.
2. The nurse observes a client with new-onset tachycardia. What should the nurse do first?
- A. Check for the client's temperature
- B. Administer prescribed beta-blockers
- C. Assess for any chest pain or discomfort
- D. Monitor the client's blood pressure
Correct answer: C
Rationale: When a client presents with new-onset tachycardia, the first action the nurse should take is to assess for any associated symptoms like chest pain or discomfort. This is important to differentiate the potential causes of tachycardia and guide appropriate interventions. Checking the client's temperature (Choice A) may be relevant in certain situations but is not the priority when tachycardia is observed. Administering prescribed beta-blockers (Choice B) should only be done after a comprehensive assessment and healthcare provider's orders. Monitoring the client's blood pressure (Choice D) is important, but assessing for chest pain or discomfort takes precedence in this scenario to rule out cardiac causes of tachycardia.
3. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?
- A. International Normalized Ratio (INR)
- B. Blood glucose levels
- C. Blood pressure
- D. Temperature
Correct answer: A
Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.
4. Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct answer: D
Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.
5. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?
- A. Continue the transfusion at a slower rate
- B. Administer an antipyretic
- C. Stop the transfusion immediately
- D. Notify the healthcare provider
Correct answer: C
Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.
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