HESI LPN
Adult Health 1 Exam 1 Questions
Question 1 of 5
Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.
Question 2 of 5
A client complains of pain at the IV site. Upon assessment, the nurse notes the site is warm, red, and swollen. What is the most likely cause of these findings?
Correct Answer: A
Rationale: The correct answer is A, Phlebitis. Phlebitis is the inflammation of a vein, often caused by irritation from an IV catheter, resulting in warmth, redness, and swelling at the site. Infiltration (choice B) refers to the leaking of IV fluids into the surrounding tissues, causing swelling and pallor, not redness and warmth like in the scenario described. An allergic reaction (choice C) would present with itching, hives, or anaphylaxis, rather than localized warmth, redness, and swelling. Fluid overload (choice D) typically manifests as generalized edema, shortness of breath, and weight gain, not localized symptoms at the IV site.
Question 3 of 5
A client with hypothyroidism is taking levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?
Correct Answer: C
Rationale: The correct answer is C: Nervousness and tremors. These symptoms may indicate hyperthyroidism resulting from excessive dosing of levothyroxine. Weight gain (Choice A) is a common symptom of hypothyroidism and may indicate undertreatment or inadequate dosing. Bradycardia (Choice B) is a symptom of hypothyroidism and may improve with levothyroxine therapy; it does not typically indicate an urgent need for healthcare provider notification. Fatigue (Choice D) is a symptom of hypothyroidism and can persist even with levothyroxine treatment, so it is not a symptom that would require immediate notification of the healthcare provider.
Question 4 of 5
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?
Correct Answer: C
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing in COPD patients. While administering bronchodilator therapy as prescribed (Choice A) is important, it is not the priority in this scenario. Encouraging deep breathing and coughing exercises (Choice B) can be beneficial but do not take precedence over positioning for improved respiratory function. Increasing the oxygen flow rate (Choice D) can be considered after the initial positioning to relieve respiratory distress, making it a later intervention.
Question 5 of 5
A client with a history of hypertension is prescribed hydrochlorothiazide (HCTZ). Which adverse effect should the nurse monitor for?
Correct Answer: B
Rationale: The correct answer is 'B. Hyponatremia.' Hydrochlorothiazide can lead to electrolyte imbalances, such as hyponatremia, due to its diuretic effect. This potential adverse effect should be closely monitored in patients taking HCTZ. Choice A, hyperkalemia, is less likely to occur with HCTZ as it tends to cause hypokalemia. Choice C, bradycardia, is not a common adverse effect of HCTZ. Choice D, hyperglycemia, is also less commonly associated with HCTZ use compared to hyponatremia.