HESI LPN
Adult Health 2 Final Exam
1. The nurse is teaching a client with hypertension about lifestyle modifications. Which recommendation is most effective for lowering blood pressure?
- A. Increase intake of red meat
- B. Engage in regular physical activity
- C. Consume a high-sodium diet
- D. Limit fluid intake to 1 liter per day
Correct answer: B
Rationale: Engaging in regular physical activity is a highly effective recommendation for lowering blood pressure and improving overall cardiovascular health. Regular exercise helps to strengthen the heart, improve blood circulation, and manage weight, all of which contribute to reducing blood pressure levels. Choices A, C, and D are incorrect. Increasing intake of red meat can lead to higher saturated fat consumption, which is detrimental to heart health. Consuming a high-sodium diet can exacerbate hypertension by increasing blood pressure. Limiting fluid intake to 1 liter per day may lead to dehydration and is not a recommended approach for managing hypertension.
2. During a severe asthma exacerbation in a client, what is the nurse's priority?
- A. Administer a rescue inhaler immediately
- B. Prepare for intubation
- C. Encourage deep breathing exercises
- D. Monitor oxygen saturation levels
Correct answer: A
Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.
3. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?
- A. Perform hand hygiene before and after handling the catheter
- B. Change the catheter every 72 hours
- C. Apply antibiotic ointment at the insertion site
- D. Irrigate the catheter daily
Correct answer: A
Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.
4. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?
- A. Place tape from the cheek to the forehead
- B. Secure tape from the nose to the ear
- C. Attach tape from the lower eyelid to the upper forehead
- D. Use circular bandaging around the head
Correct answer: C
Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.
5. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?
- A. Use the inhaler only during an asthma attack
- B. Rinse your mouth after using the inhaler
- C. Shake the inhaler before each use
- D. Exhale fully before inhaling the medication
Correct answer: C
Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.
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