HESI LPN
Adult Health 2 Final Exam Questions
Question 1 of 5
The wife is observed shaving her husband's beard with a safety razor. What should the nurse do?
Correct Answer: C
Rationale: In this situation, the nurse should encourage the wife to continue shaving her husband. The rationale behind this is that the wife is already performing the task, so abrupt interference may lead to potential harm or emotional distress. It is crucial for the nurse to carefully observe the situation and assess for any safety concerns. While teaching proper techniques (Choice B) is important, it can be addressed later in a non-critical manner to prevent skin irritation and injury. Advising to shave against the hair growth (Choice A) may cause skin irritation and cuts. Although demonstrating the correct procedure (Choice D) may be helpful, it is essential to consider the current dynamics and respect the wife's autonomy in caring for her husband.
Question 2 of 5
A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?
Correct Answer: B
Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.
Question 3 of 5
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?
Correct Answer: B
Rationale: In this scenario, the correct instruction for a client with DVT receiving anticoagulant therapy is to report any signs of bleeding to the healthcare provider (Option B). This instruction is crucial because anticoagulants increase the risk of bleeding, so early detection and management of any bleeding are essential to prevent complications. Option A is incorrect because walking is actually encouraged in DVT to prevent stasis and further clot formation. Option C is incorrect because aspirin is not recommended for pain relief in this case as it can increase the risk of bleeding due to its antiplatelet effects. Option D is also incorrect as compression stockings are typically worn during the day to promote venous return and reduce swelling, not at night. Educationally, understanding the rationale behind the correct answer reinforces the importance of patient safety and monitoring for adverse effects of medications. It also highlights the critical role of nurses in patient education to ensure optimal outcomes in the management of DVT and anticoagulant therapy. By providing accurate information, nurses empower patients to actively participate in their care and promote their overall well-being.
Question 4 of 5
A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
Correct Answer: B
Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.
Question 5 of 5
The healthcare provider is preparing to administer a 1.2mL injection to a 4-year-old. Which is the best site to administer an IM injection?
Correct Answer: A
Rationale: The correct answer is A, Vastus Lateralis. The vastus lateralis site is recommended for IM injections in small children due to its large muscle mass, making it suitable for injections in pediatric patients. Choices B, C, and D are incorrect. The radial artery is not a site for IM injections; it is a site for arterial puncture. The dorsogluteal site is not recommended for children due to potential risks, such as injury to the sciatic nerve. The rectus femoris is not typically used for IM injections in children, as other sites like the vastus lateralis are more commonly preferred.