HESI LPN
Adult Health 1 Final Exam Questions
Question 1 of 5
A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation.
Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice
B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice
C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice
D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.
Question 2 of 5
The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement?
Correct Answer: D
Rationale: The correct action for the nurse to implement is to secure the tubing to the client's gown instead of his abdomen. Securing the tubing to the client's abdomen can cause discomfort, trauma to the urethra, and increase the risk of infection. Attaching the drainage bag to the bed frame can lead to tension on the catheter, increasing the risk of dislodgement or trauma. Raising the bed does not address the issue of incorrect tubing securing. Observing the appearance of urine is important but secondary to ensuring proper tubing attachment.
Question 3 of 5
A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?
Correct Answer: A
Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (
Choice
B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (
Choice
C) may be needed but are not the immediate priority in this situation. Nitroglycerin (
Choice
D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.
Question 4 of 5
Which client is at the highest risk for developing pressure ulcers?
Correct Answer: C
Rationale: Clients with limited mobility are at the highest risk for developing pressure ulcers due to prolonged pressure on specific areas of the body. This constant pressure can lead to tissue damage and ultimately result in pressure ulcers. While age and medical conditions such as diabetes and a history of stroke can contribute to the risk of pressure ulcers, limited mobility is the most significant factor as it directly affects the ability to shift positions and relieve pressure on vulnerable areas of the body.
Therefore, the 65-year-old client with limited mobility is at the highest risk compared to the other clients. The 50-year-old client with a fractured femur may have limited mobility due to the injury, but it is temporary and may not be as prolonged as chronic limited mobility. The 30-year-old client with diabetes mellitus and the 70-year-old client with a history of stroke are at risk for developing pressure ulcers, but their conditions do not directly impact their ability to shift positions and alleviate pressure like limited mobility does.
Question 5 of 5
Which intervention is most effective in preventing the spread of infection in a healthcare setting?
Correct Answer: C
Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.