a client with dm has an above knee amputation because of severe peripheral vascular disease two days following surgery when preparing the client for d
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Nursing Elites

HESI LPN

HESI Leadership and Management Test Bank

1. A client with DM has an above-knee amputation because of severe peripheral vascular disease. Two days following surgery, when preparing the client for dinner, what is the nurse's primary responsibility?

Correct answer: A

Rationale: The correct answer is to check the client's serum glucose level. In a client with diabetes who just had surgery, monitoring the serum glucose level is crucial to ensure proper management of the condition. This helps in preventing complications related to blood sugar fluctuations. Assisting the client out of bed may be important but not the primary responsibility at this time. Placing the client in a high-Fowler's position or ensuring the residual limb is elevated are important interventions for comfort and circulation but are not the primary concern in this scenario.

2. 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.

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.

3. Which of the following is the best way to improve nursing's image?

Correct answer: D

Rationale: The correct answer is D because taking every chance to engage with the public about nursing allows for the improvement of nursing's image and the promotion of the profession. Choice A is incorrect as uniforms should reflect professionalism rather than personality. Choice B is not directly related to improving nursing's image. Choice C, while important, does not directly address improving the image of nursing through public engagement.

4. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

Correct answer: A

Rationale: The correct answer is A. Having a client on airborne precautions wear a mask when out of their room is appropriate to prevent the spread of infection. Choice B is incorrect because the healthcare provider, not the client, wears an N95 respirator mask for a client on droplet precautions. Choice C is incorrect because negative-pressure airflow rooms are used for clients with airborne infections, not compromised immunity. Choice D is incorrect because visitors, not clients, should wear a mask when visiting a client on contact precautions.

5. A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct answer: D

Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.

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