HESI LPN
Adult Health Exam 1
1. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads, 'Ilosone 100mg/5mL.' How many mL should the nurse administer at each dose?
- A. 15 mL
- B. 10 mL
- C. 20 mL
- D. 5 mL
Correct answer: A
Rationale: To determine the volume of medication needed for a 300 mg dose of Ilosone (100mg/5mL), we set up a proportion: 100 mg is to 5 mL as 300 mg is to x mL. Cross-multiplying, we get x = (300*5)/100 = 15 mL. Therefore, the nurse should administer 15 mL at each dose. Choice B (10 mL) is incorrect as it does not reflect the correct calculation based on the medication concentration. Choices C (20 mL) and D (5 mL) are also incorrect as they do not accurately calculate the volume required for the prescribed dose.
2. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?
- A. The client should bottle feed and pump her breast for 3 days following immunization
- B. The vaccine is given to produce maternal antibodies before lactation occurs
- C. The infant will receive immunization through the mother's breast milk
- D. The client should not get pregnant for 3 months after immunization
Correct answer: D
Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.
3. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?
- A. Restrict sodium intake
- B. Encourage high-protein meals
- C. Increase fluid intake
- D. Administer diuretics as prescribed
Correct answer: D
Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.
4. 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.
5. 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.
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