HESI LPN
Adult Health Exam 1 Chamberlain Questions
Question 1 of 5
What is the most important aspect of colostomy care to teach the client?
Correct Answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.
Question 2 of 5
What skin care measure should the nurse implement for a client who underwent external radiation treatment the previous day?
Correct Answer: A
Rationale: The correct measure for skin care after external radiation treatment is to cleanse the radiated area with water and pat the skin dry. This gentle cleansing without harsh chemicals or friction helps protect the integrity of radiated skin, preventing irritation or further damage. Choice B is incorrect because massaging radiated skin can cause further irritation, which should be avoided. Choice C is incorrect as rinsing with normal saline and covering with a sterile towel may not be necessary and could potentially introduce infection due to excessive moisture. Choice D is incorrect as using a soft washcloth to remove skin markings can be too abrasive for radiated skin, risking damage and irritation.
Question 3 of 5
The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.
Question 4 of 5
The client is being taught about managing chronic kidney disease (CKD). Which dietary restriction should be emphasized the most?
Correct Answer: B
Rationale: Restricting protein intake is vital in managing chronic kidney disease (CKD) as it helps decrease the kidneys' workload and slows down disease progression. High-fiber foods are generally beneficial for health and should not be limited in CKD management. Dairy products can be consumed moderately unless contraindicated. While adequate fluid intake is crucial, increasing intake excessively may not be suitable for all CKD patients, especially those with fluid restrictions. Therefore, the most crucial dietary restriction to emphasize in CKD management is restricting protein intake.
Question 5 of 5
During the shift change report at an acute care hospital, the charge nurse assigns the Licensed Practical Nurse (LPN) to care for a client. Which task is within the LPN's scope?
Correct Answer: C
Rationale: The correct answer is C. LPNs are trained to provide basic nursing care such as wound care. Providing wound care for a stage III pressure ulcer falls within the LPN's scope of practice. Administering IV medication (choice A) requires a higher level of skill and is usually the responsibility of registered nurses. Conducting initial client assessments (choice B) demands more advanced training and is typically performed by registered nurses. Teaching a diabetic client about insulin administration (choice D) involves patient education and is usually within the scope of registered nurses or other healthcare professionals with specific training in diabetic care.