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?
- A. Check the client's serum glucose level
- B. Assist the client out of bed to the chair
- C. Place the client in a high-Fowler's position
- D. Ensure that the client's residual limb is elevated
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. The Philippine Family Program seeks to improve and maintain which of the following life-saving measures?
- A. proper spacing of pregnancies
- B. proper timing of pregnancies
- C. fewer pregnancies
- D. all of the above
Correct answer: D
Rationale: The correct answer is D, all of the above. The Philippine Family Program aims to enhance and sustain proper spacing of pregnancies, proper timing of pregnancies, and reducing the number of pregnancies. These measures are essential for promoting maternal and child health, preventing complications, and ensuring better outcomes. Choices A, B, and C are all part of the comprehensive approach taken by the program to safeguard the well-being of families and contribute to overall public health.
3. The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?
- A. That the client may act on suicidal thoughts.
- B. That the client may engage in impulsive behavior.
- C. That the client may be experiencing the side effects of the medication.
- D. That the client may be at risk for developing serotonin syndrome.
Correct answer: A
Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.
4. What is the primary focus of postoperative nursing care for the client with colon trauma?
- A. Monitoring for elevated coagulation studies
- B. Observation for and prevention of fistulas
- C. Monitoring for signs of hyponatremia
- D. Observation for and prevention of infection
Correct answer: D
Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.
5. During a clinical conference with a group of nursing students, the instructor is describing burn classification. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?
- A. Skin that is reddened, dry, and slightly swollen
- B. Skin appearing wet with significant pain
- C. Skin with blistering and swelling
- D. Skin that is leathery and dry with some numbness
Correct answer: D
Rationale: Full-thickness burns are characterized by a leathery, dry appearance with numbness due to nerve damage. Choice A describes characteristics of superficial burns, which are not full-thickness. Choice B describes characteristics of partial-thickness burns with intact blisters, not full-thickness burns. Choice C describes characteristics of partial-thickness burns with blistering and swelling, not full-thickness burns.