Adult Health 2 Exam 1

Questions 49

HESI LPN

HESI LPN Test Bank

Adult Health 2 Exam 1 Questions

Question 1 of 5

The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

Correct Answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

Question 2 of 5

A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

Correct Answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

Question 3 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: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

Question 4 of 5

The nurse is caring for a client with an intravenous infusion of normal saline. The client reports pain and swelling at the IV site. What is the nurse's priority action?

Correct Answer: C

Rationale: The correct answer is to discontinue the IV infusion (Choice C). Pain and swelling at the IV site can indicate infiltration or phlebitis, which are serious complications that require immediate action. Slowing the rate of infusion (Choice A) may not address the underlying issue and can potentially worsen the condition. Applying a warm compress (Choice B) may provide temporary relief but does not address the need to discontinue the infusion. Elevating the affected arm (Choice D) is not the priority in this situation; discontinuing the infusion takes precedence to prevent further harm.

Question 5 of 5

A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

Correct Answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

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