HESI LPN
HESI Leadership and Management Quizlet
1. 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.
2. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
- A. Pleuritic pain on inspiration
- B. Dry mucus membranes in the mouth
- C. A decrease in respiratory rate from 34 to 24
- D. Decrease in chest wall expansion
Correct answer: D
Rationale: A decrease in chest wall expansion suggests that the client may be experiencing a serious complication, such as worsening pneumonia or respiratory failure, requiring immediate medical attention. This finding indicates a potential decrease in lung function, which could lead to respiratory distress. Pleuritic pain on inspiration may be related to the disease process but does not indicate an immediate need for intervention. Dry mucus membranes in the mouth may require attention but are not as critical as a decrease in chest wall expansion. A decrease in respiratory rate could be concerning but is not as urgent as a decrease in chest wall expansion, which directly impacts respiratory function.
3. A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). The nurse should monitor the client for which of the following laboratory values?
- A. Prothrombin time (PT)
- B. Serum potassium
- C. Blood urea nitrogen (BUN)
- D. White blood cell count (WBC)
Correct answer: A
Rationale: The correct answer is A: Prothrombin time (PT). Prothrombin time is monitored to assess the effectiveness of warfarin therapy. Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors, including factors II, VII, IX, and X. Monitoring the PT helps ensure that the client's blood is clotting within the desired therapeutic range to prevent complications such as recurrent DVT or excessive bleeding. Choices B, C, and D are incorrect because serum potassium, blood urea nitrogen, and white blood cell count are not directly related to monitoring warfarin therapy in a client with a history of DVT.
4. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly
- B. Provide a complex carbohydrate snack
- C. Administer 50% dextrose intravenously
- D. Give 15 grams of a fast-acting carbohydrate
Correct answer: D
Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.
5. A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
- A. File an incident report.
- B. Ask the client about his injuries with the son present.
- C. Ask the client's son to go to the waiting area.
- D. Treat and discharge the client
Correct answer: C
Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.