HESI LPN
Adult Health Exam 1 Questions
Question 1 of 5
A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?
Correct Answer: A
Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.
Question 2 of 5
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
Correct Answer: B
Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen.
Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful.
Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion.
Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.
Question 3 of 5
A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?
Correct Answer: B
Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.
Question 4 of 5
To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)
Correct Answer: D
Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.
Question 5 of 5
A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a Lumbar Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?
Correct Answer: A
Rationale: The correct answer is A. TENS units work by delivering small electrical impulses through the skin. These impulses are thought to close the 'gates of nerve conduction,' which can help in managing severe pain.
Choice B is incorrect because the dulled pain perception does not occur in the cerebral cortex by the TENS unit.
Choice C is incorrect as it describes a different method of pain management involving medication in the spinal canal.
Choice D is incorrect because TENS does not work by distracting the client's focus on pain, but rather by altering pain perception through electrical impulses.