HESI LPN
Adult Health 2 Final Exam
1. The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?
- A. Increase fiber intake.
- B. Avoid spicy foods.
- C. Avoid dairy products.
- D. Consume a high-fat diet.
Correct answer: B
Rationale: The most appropriate dietary recommendation for a client with peptic ulcer disease (PUD) is to avoid spicy foods. Spicy foods can irritate the stomach lining and exacerbate symptoms of PUD. Increasing fiber intake may be beneficial for other gastrointestinal conditions but is not the primary concern for PUD. Avoiding dairy products is not a general recommendation for PUD unless the individual has a specific intolerance. Consuming a high-fat diet can increase the risk of exacerbating PUD symptoms due to the delayed gastric emptying associated with high-fat meals.
2. The nurse observes that a post-operative client's surgical wound has reddened edges and is oozing. What is the appropriate nursing action?
- A. Apply an antibiotic ointment
- B. Clean the wound with sterile saline
- C. Cover the wound with a sterile dressing
- D. Notify the surgeon immediately
Correct answer: D
Rationale: The correct action when a post-operative client's surgical wound has reddened edges and is oozing is to notify the surgeon immediately. Reddened, oozing wound edges can indicate an infection that requires prompt evaluation and intervention by the surgical team. Applying an antibiotic ointment (Choice A) without proper assessment and guidance can be inappropriate. Cleaning the wound with sterile saline (Choice B) and covering it with a sterile dressing (Choice C) may not address the potential infection adequately, and the client may require more specialized care that the surgeon can provide.
3. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?
- A. Keeping the head of the bed elevated at 30 degrees
- B. Positioning the client in the prone position
- C. Placing the client in a lateral recumbent position
- D. Elevating the client's legs
Correct answer: B
Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.
4. 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.
5. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?
- A. Inform the UAP that suction is available at the bedside.
- B. Instruct the UAP to notify the nurse if the client chokes.
- C. Observe the UAP's ability to implement precautions during feeding.
- D. Ask the UAP about previous experience in performing this skill.
Correct answer: C
Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.
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