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

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. Alcohol, caffeine, or drugs are high-risk factors that all fall under which broad classification of risk factors?

A. Social demographic
B. Environmental
C. Biophysical
D. Psychosocial

Correct answer: D

Rationale: The correct answer is D: Psychosocial. Alcohol, caffeine, or drug use are considered psychosocial risk factors as they are related to individual behavior, lifestyle choices, and social interactions. Choices A, B, and C are incorrect. Social demographic factors (choice A) refer to characteristics of a population such as age, gender, education, income, etc. Environmental factors (choice B) include physical surroundings like air quality, housing conditions, etc. Biophysical factors (choice C) involve biological aspects like genetics, physiology, and health conditions.

3. Which statement about adjuvant medications is true and accurate?

A. Licensed practical nurses can administer adjuvant medications.
B. Adjuvant medications are schedule 2 narcotics.
C. Adjuvant medications are schedule 1 narcotics.
D. Adjuvant medications can be purchased over the counter.

Correct answer: D

Rationale: The correct answer is D because adjuvant medications are often available over the counter without a prescription. Choices A, B, and C are incorrect. Choice A is incorrect because licensed practical nurses can administer adjuvant medications depending on their scope of practice. Choices B and C are incorrect because adjuvant medications are not classified as schedule 1 or schedule 2 narcotics.

4. Which statement about appendicitis is accurate and true?

A. Appendicitis is more common among females than males.
B. A high fiber diet is a risk factor associated with appendicitis.
C. Left lower quadrant pain is suggestive of appendicitis.
D. McBurney's point tenderness is suggestive of appendicitis.

Correct answer: D

Rationale: The correct answer is D: McBurney's point tenderness is suggestive of appendicitis. McBurney's point is located in the right lower abdomen and tenderness at this point is a classic sign of appendicitis. Choice A is incorrect as appendicitis is slightly more common in males than females. Choice B is incorrect as a high fiber diet is actually considered to be protective against appendicitis. Choice C is incorrect as appendicitis typically presents with pain in the right lower quadrant, not the left.

5. What does the mnemonic PERLA stand for in the assessment of the eyes?

A. Pupils equally reactive to light and accommodation
B. Patient eyes are equally recessed and responsive to light and acuity
C. Patient eyes are equally responsive to light and acuity
D. Pupils equally reactive to light and acuity

Correct answer: A

Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.