HESI LPN
Adult Health Exam 1 Chamberlain
1. 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.
2. During a tonic-clonic seizure, what is the nurse's priority intervention?
- A. Insert an oral airway
- B. Administer oxygen via nasal cannula
- C. Restrain the client's arms and legs
- D. Protect the client's head from injury
Correct answer: D
Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.
3. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
4. A client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications. What should be emphasized?
- A. Avoiding spicy and fatty foods
- B. Eating small, frequent meals
- C. Avoiding meals before bedtime
- D. All of the above
Correct answer: D
Rationale: In managing GERD, dietary modifications play a significant role. Avoiding spicy and fatty foods helps reduce irritation, while eating small, frequent meals prevents overeating, which can trigger reflux. Avoiding meals before bedtime allows for better digestion and reduces the likelihood of acid reflux during the night. Therefore, all of the options (A, B, and C) are crucial in managing GERD symptoms, making choice D the correct answer.
5. Which organ lies retroperitoneally?
- A. Kidneys
- B. Testicles
- C. Urinary bladder
- D. Pancreas
Correct answer: A
Rationale: The correct answer is A: Kidneys. The kidneys are located retroperitoneally, behind the peritoneum, providing structural protection and maintaining a stable position within the abdominal cavity. This location helps protect them from external physical trauma. Choices B, C, and D are incorrect because testicles, urinary bladder, and pancreas are not located retroperitoneally. Testicles are located in the scrotum, the urinary bladder is located in the pelvis, and the pancreas is located in the upper abdomen, not retroperitoneally.
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