HESI LPN
Adult Health Exam 1
1. The nurse is preparing to administer an intramuscular injection to a 6-month-old infant. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Dorsogluteal muscle
- D. Vastus lateralis muscle
Correct answer: D
Rationale: The vastus lateralis muscle is the preferred site for intramuscular injections in infants due to its size and safety. The deltoid muscle is typically used for adults and older children. The ventrogluteal muscle is more commonly used in toddlers and older children. The dorsogluteal muscle is not recommended for intramuscular injections in any age group due to its proximity to major nerves and blood vessels, which poses a risk of injury or sciatic nerve damage.
2. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?
- A. Avoid driving for at least 2 weeks
- B. Resume a low-fat diet
- C. Remove the bandages from the incision after 24 hours
- D. Expect significant pain for the first week
Correct answer: C
Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.
3. A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?
- A. Take your insulin as usual
- B. Do not eat or drink after midnight
- C. Monitor your blood glucose closely
- D. Bring your glucose meter to the hospital
Correct answer: B
Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.
4. A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?
- A. Turns from side to back and returns
- B. Consistently returns smiles to mother
- C. Finds hands and plays with fingers
- D. Holds head up and supports weight with arms
Correct answer: B
Rationale: The correct answer is B because social smiling is a developmental milestone typically expected around 2 months of age. At this stage, infants start to engage more with their caregivers and show positive emotional responses. The other choices are incorrect. Choice A describes a motor skill that usually emerges later. Choice C involves more coordination and exploration, which is not typically seen by 2 months. Choice D relates to head control and arm strength, which also develop progressively but may not be fully achieved by 2 months.
5. When teaching a diabetic client about foot care, what information is most important?
- A. Inspect feet daily
- B. Wear cotton socks
- C. Use lukewarm water to wash feet
- D. Cut nails straight across
Correct answer: A
Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.
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