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. The nurse is caring for a client who underwent a total knee replacement yesterday. What activity level should the nurse encourage today?
- A. Bed rest with bathroom privileges only
- B. Frequent, short walks with assistance
- C. Range of motion exercises to the knee every four hours
- D. Leg elevation to reduce swelling
Correct answer: B
Rationale: After a total knee replacement, early ambulation is crucial for promoting circulation and preventing complications like thrombosis. Bed rest should be avoided as it can increase the risk of complications. Range of motion exercises are important but should be performed gradually and not excessively. Leg elevation is beneficial for reducing swelling but should not be the primary activity level encouraged immediately after surgery.
3. 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.
4. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?
- A. Place a new pad and weigh the pad removed to determine blood loss.
- B. Massage the fundus and express clots.
- C. Start an IV and begin an oxytocin infusion.
- D. Clean the perineal area and encourage her to breastfeed.
Correct answer: B
Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.
5. The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.
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