HESI LPN
Adult Health Exam 1 Questions
Question 1 of 5
4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.
Question 2 of 5
The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 3 of 5
During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?
Correct Answer: C
Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.
Question 4 of 5
What is the most important information the nurse should teach a diabetic client about foot care?
Correct Answer: A
Rationale: The correct answer is to inspect feet daily. For diabetic clients, daily foot inspection is crucial in preventing complications like infections and ulcers. By checking their feet regularly, clients can identify any issues early and seek appropriate medical care. The other choices are important aspects of foot care for diabetic clients but not as critical as daily foot inspections. Wearing cotton socks helps in moisture control, using lukewarm water to wash feet helps prevent skin damage, and cutting nails straight across prevents ingrown nails. However, daily foot inspection is the most vital as it allows for early detection of any potential problems, which is key in diabetic foot care.
Question 5 of 5
A client with type 1 diabetes mellitus is learning to administer insulin. What is the best site for the nurse to recommend for insulin injection?
Correct Answer: A
Rationale: The correct answer is the abdomen. The abdomen is the recommended site for insulin injection due to its faster absorption rate compared to other sites. Insulin injected into the abdomen is absorbed more quickly, leading to better glycemic control. The thigh and upper arm are also common sites for insulin injection, but they have slower absorption rates than the abdomen. The buttock is not a preferred site for insulin injection due to inconsistent absorption and potential risk of injecting into muscle instead of fatty tissue.