HESI LPN
Adult Health 2 Exam 1
1. What is the primary function of neutrophils?
- A. Heparin secretion
- B. Transport oxygen
- C. Phagocytotic action
- D. Antibody formation
Correct answer: C
Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.
2. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?
- A. Check the client's respiratory rate
- B. Assess the client's pain level
- C. Monitor the client's blood pressure
- D. Evaluate the client's level of consciousness
Correct answer: A
Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.
3. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?
- A. Advise the client that suctioning will be used to obtain another specimen
- B. Re-instruct the client in coughing techniques to obtain another specimen
- C. Provide the client a glass of water and mouthwash to rinse the mouth
- D. Label the container and place the container in a biohazard transport bag
Correct answer: C
Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.
4. The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?
- A. Warning signs of a potential heart attack
- B. Importance of medication adherence
- C. Follow-up appointment details
- D. All of the above
Correct answer: D
Rationale: When preparing a client for discharge after a myocardial infarction, the nurse should prioritize providing comprehensive instructions. This includes educating the client about warning signs of a potential heart attack to recognize symptoms early, stressing the importance of medication adherence for optimal recovery and prevention of further cardiac events, and ensuring understanding of follow-up appointment details for ongoing monitoring and care. All these aspects are crucial in preventing complications and promoting the client's well-being. Therefore, selecting 'All of the above' as the correct answer is the most appropriate choice. Choices A, B, and C are all essential components of a holistic discharge plan for a client post-myocardial infarction.
5. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?
- A. Phenytoin level
- B. Sodium level
- C. Hemoglobin level
- D. White blood cell count
Correct answer: A
Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.
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