HESI LPN
Adult Health 1 Exam 1
1. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?
- A. Reassess the pain and its characteristics
- B. Administer prescribed pain medication
- C. Notify the surgeon
- D. Encourage the use of relaxation techniques
Correct answer: A
Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.
2. When providing care for a client receiving palliative care for terminal cancer, what should the nurse prioritize?
- A. Pain management
- B. Arranging family visits
- C. Discussing advance directives
- D. Providing nutritional support
Correct answer: A
Rationale: When caring for a client receiving palliative care for terminal cancer, the nurse should prioritize pain management. Effective pain management is crucial in enhancing the quality of life for terminally ill patients. While arranging family visits and discussing advance directives are important aspects of care, pain management takes precedence in providing comfort and alleviating suffering. Nutritional support is essential but may be of lesser priority compared to pain management in this context.
3. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?
- A. Educate the client about the importance of a low-sodium diet
- B. Replace the meal with a low-sodium option
- C. Report the error to the dietary department
- D. Encourage the client to avoid eating the high-sodium foods
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.
4. What are the final factors that contribute to blood pressure? (Select all that apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct answer: D
Rationale: Neuroendocrine hormones play a crucial role in regulating blood pressure by influencing factors like fluid balance, blood volume, and vessel constriction. While heart rate, stroke volume, and peripheral resistance are important factors affecting blood pressure, the final parameters that directly produce blood pressure are influenced by neuroendocrine hormones. Therefore, choice D is the correct answer. Choices A, B, and C are involved in the regulation of blood pressure but are not the final parameters that directly produce it.
5. When observing a newly admitted elderly client with dementia resisting care, what approach should the nurse take to facilitate cooperation?
- A. Use short, simple sentences and maintain a calm demeanor
- B. Involve family members to provide reassurance
- C. Offer choices to empower the client
- D. All of the above
Correct answer: D
Rationale: When dealing with a newly admitted elderly client with dementia who is resistant to care, it is crucial to employ multiple strategies to facilitate cooperation. Using short, simple sentences and maintaining a calm demeanor can help the client better understand instructions and reduce agitation. Involving family members can provide comfort and reassurance to the client, potentially decreasing resistance. Offering choices allows the client to feel a sense of control and autonomy in their care, which can increase cooperation and reduce challenging behaviors. Therefore, a combination of clear communication, family involvement, and providing choices is essential to effectively engage and care for a client with dementia. Choices A, B, and C all play crucial roles in addressing the needs of the client, making 'All of the above' the correct answer.
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