HESI LPN
Adult Health 2 Exam 1
1. The healthcare provider is assessing a client with a suspected diagnosis of appendicitis. Which symptom is most indicative of this condition?
- A. Right upper quadrant pain
- B. Nausea and vomiting
- C. Rebound tenderness at McBurney's point
- D. Hematuria
Correct answer: C
Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This symptom is due to irritation of the peritoneum when pressure is released during palpation. Right upper quadrant pain (Choice A) is more commonly associated with gallbladder issues. Nausea and vomiting (Choice B) can occur in various abdominal conditions and are not specific to appendicitis. Hematuria (Choice D) is the presence of blood in the urine and is not a typical symptom of appendicitis.
2. What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
- A. Monitor the client's vital signs every 4 hours
- B. Assess the client's lower extremities for sensation
- C. Instruct the client to maintain bed rest
- D. Wash any paste from the client's hair and scalp
Correct answer: D
Rationale: The correct action the nurse should implement after an EEG is to wash any paste from the client's hair and scalp. This is crucial to prevent irritation and infection at the EEG site. Monitoring vital signs every 4 hours is not specifically indicated after an EEG. Assessing the client's lower extremities for sensation is unrelated to caring for a client post-EEG. While rest may be recommended after the procedure, there is no standard requirement for a specific duration of bed rest.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated
- B. Avoid wearing oxygen during physical activity
- C. Do not smoke while using oxygen
- D. Store oxygen tanks in a cool, dark place
Correct answer: C
Rationale: The correct answer is C: 'Do not smoke while using oxygen.' Smoking while using oxygen can lead to a serious fire hazard, as oxygen supports combustion. This instruction is crucial to prevent potential harm to the client. Choices A, B, and D are incorrect. Using oxygen at the highest flow rate tolerated can be harmful, avoiding wearing oxygen during physical activity may limit the client's mobility unnecessarily, and storing oxygen tanks in a cool, dark place, although important, is not as critical as the instruction to avoid smoking while using oxygen.
4. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?
- A. Slow the rate of transfusion.
- B. Administer an antipyretic.
- C. Stop the transfusion immediately.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.
5. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
- A. Filtration
- B. Diffusion
- C. Osmosis
- D. Active transport
Correct answer: C
Rationale: The correct answer is C: Osmosis. Osmosis is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space to maintain cellular balance. In osmosis, water moves across a semi-permeable membrane from an area of low solute concentration (hypotonic) to an area of high solute concentration (hypertonic). This process helps regulate the water content inside cells. Choices A, B, and D are incorrect. Filtration involves the movement of solutes and solvents through a membrane due to a pressure difference, diffusion is the movement of solutes from an area of high concentration to low concentration, and active transport requires energy to move substances against their concentration gradient.
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