HESI LPN
Adult Health 2 Final Exam
1. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?
- A. Check for tightness of the cast
- B. Elevate the limb
- C. Apply ice to the area
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.
2. A client reports pain after medication administration. What is the next best step for the nurse?
- A. Reassess the client’s pain
- B. Increase the pain medication dose
- C. Apply a cold compress
- D. Contact the healthcare provider
Correct answer: A
Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.
3. A client with a diagnosis of anemia is being discharged with a prescription for ferrous sulfate. What should the nurse include in the teaching plan?
- A. Take the medication with milk to enhance absorption
- B. Expect stools to be dark in color
- C. Take the medication before bedtime
- D. Avoid foods high in vitamin C
Correct answer: B
Rationale: The correct answer is B: 'Expect stools to be dark in color.' Dark stools are a common side effect of iron supplementation due to the unabsorbed iron, and this is not a cause for concern. Choice A is incorrect because taking iron with milk can decrease its absorption due to calcium binding. Choice C is incorrect as there are no specific recommendations to take ferrous sulfate before bedtime. Choice D is also incorrect as vitamin C actually enhances iron absorption and should not be avoided.
4. The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?
- A. Vastus Lateralis
- B. Radial artery
- C. Dorsogluteal
- D. Rectus femoris
Correct answer: A
Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.
5. When teaching a client about managing hypertension, what dietary advice should be emphasized?
- A. Reduce sodium intake
- B. Increase potassium intake
- C. Limit alcohol consumption
- D. All of the above
Correct answer: D
Rationale: When managing hypertension, it is crucial to adopt comprehensive dietary changes. This includes reducing sodium intake to help lower blood pressure, increasing potassium intake to counteract the effects of sodium and help regulate blood pressure, and limiting alcohol consumption as excessive alcohol can raise blood pressure. Therefore, emphasizing all the options provided (A, B, and C) is essential in effectively managing hypertension and reducing overall cardiovascular risk. Choices A, B, and C are not individually sufficient as a single dietary modification but collectively work together to support blood pressure management.
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