HESI LPN
HESI Leadership and Management Quizlet
1. A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
2. What is idiopathic thrombocytopenia purpura?
- A. Highly similar to disseminated intravascular coagulation (DIC).
- B. Caused by the overproduction of platelets.
- C. A bleeding disorder that is characterized by too few platelets.
- D. Treated with immune system-boosting medications.
Correct answer: C
Rationale: Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by a low number of platelets in the blood. This condition is not highly similar to disseminated intravascular coagulation (DIC), which involves abnormal clotting throughout the body (coagulation), leading to depletion of platelets. Choice B is incorrect because idiopathic thrombocytopenic purpura is actually characterized by a decrease in platelet count, not an overproduction. While immune system-boosting medications may be used in some cases, the primary treatment for idiopathic thrombocytopenic purpura focuses on increasing platelet counts or managing symptoms.
3. Which of the following healthcare providers can legally have access to all, or part, of a patient's medical record because they have a 'need to know'? Select one that does not apply.
- A. Student nurses caring for a particular patient
- B. Registered nurses when they are not caring for a particular patient
- C. The Vice President for nursing who is investigating a patient fall
- D. Licensed practical nurses caring for a particular patient
Correct answer: B
Rationale: Student nurses, licensed practical nurses, the Vice President for nursing investigating a fall, and quality assurance nurses have a 'need to know' basis to access patient records. Registered nurses who are not directly involved in the care of a patient do not have a legitimate reason or 'need to know' to access that patient's medical records, making choice B the correct answer. The Vice President for nursing investigating a specific incident and licensed practical nurses directly involved in a patient's care have legitimate reasons to access the medical records, ensuring continuity and quality of care.
4. A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.
5. Which of the following assessment tools is used to determine the patient's level of consciousness?
- A. The Snellen Scale
- B. The Norton Scale
- C. The Morse Scale
- D. The Glasgow Scale
Correct answer: D
Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.
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