HESI LPN
Adult Health Exam 1
1. During a community health fair, a nurse is providing education on the effects of smoking. What is the most important information to include?
- A. Smoking can lead to cosmetic issues like tooth staining.
- B. Smoking is a leading cause of preventable death worldwide.
- C. Smoking temporarily elevates mood and alertness.
- D. Smoking is an expensive habit.
Correct answer: B
Rationale: The correct answer is B: 'Smoking is a leading cause of preventable death worldwide.' This information is crucial as it highlights the severe health risks associated with smoking, emphasizing the importance of cessation for overall health. Choice A is incorrect because cosmetic issues like tooth staining are not as significant as the life-threatening consequences of smoking. Choice C is incorrect because although smoking may temporarily elevate mood and alertness due to nicotine, this does not outweigh the serious health implications. Choice D is incorrect as while smoking is indeed an expensive habit, the focus should be on the health-related consequences to stress the urgency of quitting.
2. What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?
- A. Check tube placement before each feeding
- B. Flush the tube with water before and after each feeding
- C. Elevate the head of the bed to 30 degrees
- D. Administer the feeding at room temperature
Correct answer: A
Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.
3. The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?
- A. Keep the client in a low Fowler's position
- B. Maintain hip abduction with pillows
- C. Encourage early ambulation
- D. Place the client in a prone position
Correct answer: B
Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.
4. What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag only when necessary
- B. Eat a low-residue diet
- C. Assess the stoma for color and swelling
- D. Irrigate the colostomy only if advised by a healthcare provider
Correct answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.
5. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?
- A. Application of topical antibacterial cream
- B. Use of careful hand washing technique
- C. Administration of plasma expanders
- D. Limiting visitors to the burned client
Correct answer: B
Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.
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