which of the following assessment tools is used to determine the patients level of consciousness
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Nursing Elites

HESI LPN

HESI Leadership and Management Quizlet

1. Which of the following assessment tools is used to determine the patient's level of consciousness?

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.

2. A client with type 1 DM has a finger stick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:

Correct answer: C

Rationale: In this scenario, the client with type 1 DM has a high glucose level at bedtime. The appropriate action for the nurse is to administer the sliding scale insulin as ordered. This insulin regimen is specifically designed to manage high blood glucose levels. Calling the physician is not necessary as the protocol for sliding scale insulin is already in place. Encouraging fluid intake or providing orange juice is not the correct intervention for addressing high blood glucose levels in this case.

3. Which of the following methods of insulin administration would be used in the initial treatment of hyperglycemia in a client with diabetic ketoacidosis?

Correct answer: D

Rationale: The correct answer is D: IV bolus, followed by continuous infusion. In the initial treatment of hyperglycemia in a client with diabetic ketoacidosis, insulin is administered via IV bolus to quickly reduce blood glucose levels, followed by a continuous infusion to maintain control. Subcutaneous and intramuscular routes are not used in this situation as they are not rapid or predictable enough to address the acute hyperglycemia seen in diabetic ketoacidosis. IV bolus alone without the continuous infusion may not provide sustained control of blood glucose levels, making choice C incorrect.

4. A nurse is caring for a client who has cancer. The client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

Correct answer: C

Rationale: The nurse should not provide treatment information without the client's consent.

5. 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.

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