HESI LPN
Adult Health 2 Exam 1 Questions
Question 1 of 5
The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?
Correct Answer: A
Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.
Question 3 of 5
A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?
Correct Answer: C
Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.
Question 4 of 5
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?
Correct Answer: B
Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.
Question 5 of 5
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?
Correct Answer: D
Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.