HESI Comprehensive Exam
Questions and Answers Updated
2026
EnalaprilBmaleateBisBprescribedBforBaBhospitalizedBclient.BWhichBassessmentBdoesBtheBnurseB
performBasBaBpriorityBbeforeBadministeringBtheBmedication?
CheckingBtheBclient'sBbloodBpressureB
CheckingBtheBclient'sBperipheralBpulses
CheckingBtheBmostBrecentBpotassiumBlevel
CheckingBtheBclient'sBintake-and-outputBrecordBforBtheBlastB24BhoursB-
BAnswerCheckingBtheBclient'sBbloodBpressureB
Rationale:BEnalaprilBmaleateBisBanBangiotensin-
convertingBenzymeB(ACE)BinhibitorBusedBtoBtreatBhypertension.BOneBcommonBsideBeffectBisBp
osturalBhypotension.BThereforeBtheBnurseBwouldBcheckBtheBclient'sBbloodBpressureBimmediate
lyBbeforeBadministeringBeachBdose.BCheckingBtheBclient'sBperipheralBpulses,BtheBresultsBofBth
eBmostBrecentBpotassiumBlevel,BandBtheBintakeBandBoutputBforBtheBpreviousB24BhoursBareBn
otBspecificallyBassociatedBwithBthisBmediation.
ABclientBisBscheduledBtoBundergoBanBupperBgastrointestinalB(GI)Bseries,BandBtheBnurseBprovid
esBinstructionsBtoBtheBclientBaboutBtheBtest.BWhichBstatementBbyBtheBclientBindicatesBaBnee
dBforBfurtherBinstruction?
"TheBtestBwillBtakeBaboutB30Bminutes."
"IBneedBtoBfastBforB8BhoursBbeforeBtheBtest."
"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBene
maBonBtheBmorningBofBtheBtest."B
"IBneedBtoBtakeBaBlaxativeBafterBtheBtestBisBcompleted,BbecauseBtheBliquidBthatBI'llBhaveBtoB
drinkBforBtheBtestBcanBbeBconstipating."B-
BAnswer"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBF
leetBenemaBonBtheBmorningBofBtheBtest."B
Rationale:BNoBspecialBpreparationBisBnecessaryBbeforeBaBGIBseries,BexceptBthatBNPOB(nothing
BbyBmouth)BstatusBmustBbeBmaintainedBforB8BhoursBbeforeBtheBtest.BAnBupperBGIBseriesBinv
olvesBvisualizationBofBtheBesophagus,Bduodenum,BandBupperBjejunumBbyBmeansBofBtheBuseB
ofBaBcontrastBmedium.BItBinvolvesBswallowingBaBcontrastBmediumB(usuallyBbarium),BwhichBisB
,administeredBinBaBflavoredBmilkshake.BFilmsBareBtakenBatBintervalsBduringBtheBtest,BwhichBta
kesBaboutB30Bminutes.BAfterBanBupperBGIBseries,BtheBclientBisBprescribedBaBlaxativeBtoBhaste
nBeliminationBofBtheBbarium.BBariumBthatBremainsBinBtheBcolonBmayBbecomeBhardBandBdiffi
cultBtoBexpel,BleadingBtoBfecalBimpaction.
ABnurseBonBtheBeveningBshiftBchecksBaBprimaryBhealthBcareBprovider'sBprescriptionsBandBnot
esBthatBtheBdoseBofBaBprescribedBmedicationBisBhigherBthanBtheBnormalBdose.BTheBnurseBca
llsBtheBprimaryBhealthBcareBprovider'sBansweringBserviceBandBisBtoldBthatBtheBprimaryBhealth
BcareBproviderBisBoffBforBtheBnightBandBwillBbeBavailableBinBtheBmorning.BWhatBshouldBtheB
nurseBdoBnext?
CallBtheBnursingBsupervisor
AskBtheBansweringBserviceBtoBcontactBtheBon-callBprimaryBhealthBcareBproviderB
WithholdBtheBmedicationBuntilBtheBprimaryBhealthBcareBproviderBcanBbeBreachedBinBtheBmor
ning
AdministerBtheBmedicationBbutBconsultBtheBprimaryBhealthBcareBproviderBwhenBheBbecomesB
availableB-BAnswerAskBtheBansweringBserviceBtoBcontactBtheBon-
callBprimaryBhealthBcareBproviderB
Rationale:BTheBnurseBhasBaBdutyBtoBprotectBtheBclientBfromBharm.BABnurseBwhoBbelievesBth
atBaBprimaryBhealthBcareBprovider'sBprescriptionBmayBbeBinBerrorBisBresponsibleBforBclarifying
BtheBprescriptionBbeforeBcarryingBitBout.BThereforeBtheBnurseBwouldBnotBadministerBtheBmed
ication;Binstead,BtheBnurseBwouldBwithholdBtheBmedicationBuntilBtheBdoseBcanBbeBclarified.BT
heBnurseBwouldBnotBwaitBuntilBtheBnextBmorningBtoBobtainBclarification.BItBisBprematureBtoB
callBtheBnursingBsupervisor.
AnBemergencyBdepartmentB(ED)BnurseBisBmonitoringBaBclientBwithBsuspectedBacuteBmyocardi
alBinfarctionB(MI)BwhoBisBawaitingBtransferBtoBtheBcoronaryBintensiveBcareBunit.BTheBnurseBn
otesBtheBsuddenBonsetBofBprematureBventricularBcontractionsB(PVCs)BonBtheBmonitor,Bchecks
BtheBclient'sBcarotidBpulse,BandBdeterminesBthatBtheBPVCsBareBnotBperfusing.BWhatBisBtheBn
urse'sBmostBappropriateBaction?
DocumentBtheBfindings
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
ContinueBtoBmonitorBtheBclient'sBcardiacBstatus
InformBtheBclientBthatBPVCsBareBexpectedBafterBanBMIB-
BAnswerAskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
,Rationale:BTheBmostBappropriateBactionBbyBtheBnurseBwouldBbeBtoBaskBtheBEDBhealthBcareB
providerBtoBcheckBtheBclient.BPVCsBareBaBresultBofBincreasedBirritabilityBofBventricularBcells.B
PeripheralBpulsesBmayBbeBabsentBorBdiminishedBwithBtheBPVCsBthemselvesBbecauseBtheBdecr
easedBstrokeBvolumeBofBtheBprematureBbeatsBmayBinBturnBdecreaseBperipheralBperfusion.BBe
causeBotherBrhythmsBalsoBcauseBwidenedBQRSBcomplexes,BitBisBessentialBthatBtheBnurseBdete
rmineBwhetherBtheBprematureBbeatsBareBresultingBinBperfusionBofBtheBextremities.BThisBisBd
oneBbyBpalpatingBtheBcarotid,Bbrachial,BorBfemoralBarteryBwhileBobservingBtheBmonitorBforBw
idenedBcomplexesBorBbyBauscultatingBforBapicalBheartBsounds.BInBtheBsituationBofBacuteBMI,B
PVCsBmayBbeBconsideredBwarningBdysrhythmias,BpossiblyBheraldingBtheBonsetBofBventricularBt
achycardiaBorBventricularBfibrillation.BTherefore,BtheBnurseBwouldBnotBtellBtheBclientBthatBthe
BPVCsBareBexpected.BAlthoughBtheBnurseBwillBcontinueBtoBmonitorBtheBclientBandBdocument
BtheBfindings,BtheseBareBnotBtheBmostBappropriateBactionsBofBthoseBprovided.
NPOBstatusBisBimposedB8BhoursBbeforeBtheBprocedureBonBaBclientBscheduledBtoBundergoBele
ctroconvulsiveBtherapyB(ECT)BatB1Bp.m.BOnBtheBmorningBofBtheBprocedure,BtheBnurseBchecks
BtheBclient'sBrecordBandBnotesBthatBtheBclientBroutinelyBtakesBanBoralBantihypertensiveBmedi
cationBeachBmorning.BWhatBactionBshouldBtheBnurseBtake?
AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
WithholdBtheBantihypertensiveBandBadministerBitBatBbedtime
AdministerBtheBmedicationBbyBwayBofBtheBintravenousB(IV)Broute
HoldBtheBantihypertensiveBandBresumeBitsBadministrationBonBtheBdayBafterBtheBECTB-
BAnswerAdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
Rationale:BTheBnurseBshouldBadministerBtheBantihypertensiveBwithBaBsmallBsipBofBwater.BGen
eralBanesthesiaBisBrequiredBforBECT,BsoBNPOBstatusBisBimposedBforB6BtoB8BhoursBbeforeBtrea
tmentBtoBhelpBpreventBaspiration.BExceptionsBincludeBclientsBwhoBroutinelyBreceiveBcardiacBm
edications,BantihypertensiveBagents,BorBhistamineB(H2)Bblockers,BwhichBshouldBbeBadministere
dBseveralBhoursBbeforeBtreatmentBwithBaBsmallBsipBofBwater.BWithholdingBtheBantihypertensi
veBandBadministeringBitBatBbedtimeBandBwithholdingBtheBantihypertensiveBandBresumingBadm
inistrationBonBtheBdayBafterBtheBECTBareBincorrectBactions,BbecauseBantihypertensivesBmustBb
eBadministeredBonBtime;Botherwise,BtheBriskBforBreboundBhypertensionBexists.BTheBnurseBwo
uldBnotBadministerBaBmedicationBbyBwayBofBaBrouteBthatBhasBnotBbeenBprescribed.
ABclientBwhoBrecentlyBunderwentBcoronaryBarteryBbypassBgraftBsurgeryBcomesBtoBtheBprimar
yBhealthBcareBprovider'sBofficeBforBaBfollow-
upBvisit.BOnBassessment,BtheBclientBtellsBtheBnurseBthatBheBisBfeelingBdepressed.BWhichBresp
onseBbyBtheBnurseBisBtherapeutic?
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
, "That'sBaBnormalBresponseBafterBthisBtypeBofBsurgery."
"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBthisBdepression."
"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth."B-
BAnswer"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
Rationale:BTheBtherapeuticBresponseBbyBtheBnurseBis,B"TellBmeBmoreBaboutBwhatByou'reBfeeli
ng."BWhenBaBclientBexpressesBfeelingsBofBdepression,BitBisBextremelyBimportantBforBtheBnurs
eBtoBfurtherBexploreBtheseBfeelingsBwithBtheBclient.BInBstating,B"ThisBisBaBnormalBresponseBa
fterBthisBtypeBofBsurgery"BtheBnurseBprovidesBfalseBreassuranceBandBavoidsBaddressingBtheBcl
ient'sBfeelings.B"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBtheBdepression"BisBa
lsoBaBfalseBreassurance,BandBitBdoesBnotBencourageBtheBexpressionBofBfeelings.B"EveryBclient
BwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth"BisBaBgeneralizationBthatBavo
idsBtheBclient'sBfeelings.
ABclientBinBlaborBexperiencesBspontaneousBruptureBofBtheBmembranes.BTheBnurseBimmediatel
yBcountsBtheBfetalBheartBrateB(FHR)BforB1BfullBminuteBandBthenBchecksBtheBamnioticBfluid.BT
heBnurseBnotesBthatBtheBfluidBisByellowBandBhasBaBstrongBodor.BWhichBactionBshouldBbeBth
eBnurse'sBpriority?
ContactBtheBprimaryBhealthBcareBproviderB
DocumentBtheBfindings
CheckBtheBfluidBforBprotein
ContinueBtoBmonitorBtheBclientBandBtheBFHRB-
BAnswerContactBtheBprimaryBhealthBcareBproviderB
Rationale:BTheBpriorityBactionBisBforBtheBnurseBtoBcontactBtheBprimaryBhealthBcareBprovider.B
TheBFHRBisBassessedBforBatBleastB1BminuteBwhenBtheBmembranesBrupture.BTheBnurseBalsoBc
hecksBtheBquantity,Bcolor,BandBodorBofBtheBamnioticBfluid.BTheBfluidBshouldBbeBclearB(oftenB
withBbitsBofBvernix)BandBhaveBaBmildBodor.BFluidBwithBaBfoulBorBstrongBodor,BcloudyBappear
ance,BorByellowBcolorationBsuggestsBchorioamnionitisBandBwarrantsBnotifyingBtheBprimaryBhea
lthBcareBprovider.BABlargeBamountBofBvernixBinBtheBfluidBsuggestsBthatBtheBfetusBisBpreterm.
BGreenish,Bmeconium-
stainedBfluidBmayBbeBseenBinBcasesBofBposttermBgestationBorBplacentalBinsufficiency.BCheckin
gBtheBfluidBforBproteinBisBnotBassociatedBwithBtheBdataBinBtheBquestion.BTheBnurseBwouldBc
ontinueBtoBmonitorBtheBclientBandBtheBFHRBandBwouldBdocumentBtheBfindings.
ABnurseBhasBassistedBaBprimaryBhealthBcareBproviderBinBinsertingBaBcentralBvenousBaccessBd
eviceBintoBaBclientBwithBaBdiagnosisBofBsevereBmalnutritionBwhoBwillBbeBreceivingBparenteral
BnutritionB(PN).BAfterBinsertionBofBtheBcatheterBwhatBdoesBtheBnurseBimmediatelyBdo?
Questions and Answers Updated
2026
EnalaprilBmaleateBisBprescribedBforBaBhospitalizedBclient.BWhichBassessmentBdoesBtheBnurseB
performBasBaBpriorityBbeforeBadministeringBtheBmedication?
CheckingBtheBclient'sBbloodBpressureB
CheckingBtheBclient'sBperipheralBpulses
CheckingBtheBmostBrecentBpotassiumBlevel
CheckingBtheBclient'sBintake-and-outputBrecordBforBtheBlastB24BhoursB-
BAnswerCheckingBtheBclient'sBbloodBpressureB
Rationale:BEnalaprilBmaleateBisBanBangiotensin-
convertingBenzymeB(ACE)BinhibitorBusedBtoBtreatBhypertension.BOneBcommonBsideBeffectBisBp
osturalBhypotension.BThereforeBtheBnurseBwouldBcheckBtheBclient'sBbloodBpressureBimmediate
lyBbeforeBadministeringBeachBdose.BCheckingBtheBclient'sBperipheralBpulses,BtheBresultsBofBth
eBmostBrecentBpotassiumBlevel,BandBtheBintakeBandBoutputBforBtheBpreviousB24BhoursBareBn
otBspecificallyBassociatedBwithBthisBmediation.
ABclientBisBscheduledBtoBundergoBanBupperBgastrointestinalB(GI)Bseries,BandBtheBnurseBprovid
esBinstructionsBtoBtheBclientBaboutBtheBtest.BWhichBstatementBbyBtheBclientBindicatesBaBnee
dBforBfurtherBinstruction?
"TheBtestBwillBtakeBaboutB30Bminutes."
"IBneedBtoBfastBforB8BhoursBbeforeBtheBtest."
"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBFleetBene
maBonBtheBmorningBofBtheBtest."B
"IBneedBtoBtakeBaBlaxativeBafterBtheBtestBisBcompleted,BbecauseBtheBliquidBthatBI'llBhaveBtoB
drinkBforBtheBtestBcanBbeBconstipating."B-
BAnswer"IBneedBtoBdrinkBcitrateBofBmagnesiaBtheBnightBbeforeBtheBtestBandBgiveBmyselfBaBF
leetBenemaBonBtheBmorningBofBtheBtest."B
Rationale:BNoBspecialBpreparationBisBnecessaryBbeforeBaBGIBseries,BexceptBthatBNPOB(nothing
BbyBmouth)BstatusBmustBbeBmaintainedBforB8BhoursBbeforeBtheBtest.BAnBupperBGIBseriesBinv
olvesBvisualizationBofBtheBesophagus,Bduodenum,BandBupperBjejunumBbyBmeansBofBtheBuseB
ofBaBcontrastBmedium.BItBinvolvesBswallowingBaBcontrastBmediumB(usuallyBbarium),BwhichBisB
,administeredBinBaBflavoredBmilkshake.BFilmsBareBtakenBatBintervalsBduringBtheBtest,BwhichBta
kesBaboutB30Bminutes.BAfterBanBupperBGIBseries,BtheBclientBisBprescribedBaBlaxativeBtoBhaste
nBeliminationBofBtheBbarium.BBariumBthatBremainsBinBtheBcolonBmayBbecomeBhardBandBdiffi
cultBtoBexpel,BleadingBtoBfecalBimpaction.
ABnurseBonBtheBeveningBshiftBchecksBaBprimaryBhealthBcareBprovider'sBprescriptionsBandBnot
esBthatBtheBdoseBofBaBprescribedBmedicationBisBhigherBthanBtheBnormalBdose.BTheBnurseBca
llsBtheBprimaryBhealthBcareBprovider'sBansweringBserviceBandBisBtoldBthatBtheBprimaryBhealth
BcareBproviderBisBoffBforBtheBnightBandBwillBbeBavailableBinBtheBmorning.BWhatBshouldBtheB
nurseBdoBnext?
CallBtheBnursingBsupervisor
AskBtheBansweringBserviceBtoBcontactBtheBon-callBprimaryBhealthBcareBproviderB
WithholdBtheBmedicationBuntilBtheBprimaryBhealthBcareBproviderBcanBbeBreachedBinBtheBmor
ning
AdministerBtheBmedicationBbutBconsultBtheBprimaryBhealthBcareBproviderBwhenBheBbecomesB
availableB-BAnswerAskBtheBansweringBserviceBtoBcontactBtheBon-
callBprimaryBhealthBcareBproviderB
Rationale:BTheBnurseBhasBaBdutyBtoBprotectBtheBclientBfromBharm.BABnurseBwhoBbelievesBth
atBaBprimaryBhealthBcareBprovider'sBprescriptionBmayBbeBinBerrorBisBresponsibleBforBclarifying
BtheBprescriptionBbeforeBcarryingBitBout.BThereforeBtheBnurseBwouldBnotBadministerBtheBmed
ication;Binstead,BtheBnurseBwouldBwithholdBtheBmedicationBuntilBtheBdoseBcanBbeBclarified.BT
heBnurseBwouldBnotBwaitBuntilBtheBnextBmorningBtoBobtainBclarification.BItBisBprematureBtoB
callBtheBnursingBsupervisor.
AnBemergencyBdepartmentB(ED)BnurseBisBmonitoringBaBclientBwithBsuspectedBacuteBmyocardi
alBinfarctionB(MI)BwhoBisBawaitingBtransferBtoBtheBcoronaryBintensiveBcareBunit.BTheBnurseBn
otesBtheBsuddenBonsetBofBprematureBventricularBcontractionsB(PVCs)BonBtheBmonitor,Bchecks
BtheBclient'sBcarotidBpulse,BandBdeterminesBthatBtheBPVCsBareBnotBperfusing.BWhatBisBtheBn
urse'sBmostBappropriateBaction?
DocumentBtheBfindings
AskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
ContinueBtoBmonitorBtheBclient'sBcardiacBstatus
InformBtheBclientBthatBPVCsBareBexpectedBafterBanBMIB-
BAnswerAskBtheBEDBprimaryBhealthBcareBproviderBtoBcheckBtheBclientB
,Rationale:BTheBmostBappropriateBactionBbyBtheBnurseBwouldBbeBtoBaskBtheBEDBhealthBcareB
providerBtoBcheckBtheBclient.BPVCsBareBaBresultBofBincreasedBirritabilityBofBventricularBcells.B
PeripheralBpulsesBmayBbeBabsentBorBdiminishedBwithBtheBPVCsBthemselvesBbecauseBtheBdecr
easedBstrokeBvolumeBofBtheBprematureBbeatsBmayBinBturnBdecreaseBperipheralBperfusion.BBe
causeBotherBrhythmsBalsoBcauseBwidenedBQRSBcomplexes,BitBisBessentialBthatBtheBnurseBdete
rmineBwhetherBtheBprematureBbeatsBareBresultingBinBperfusionBofBtheBextremities.BThisBisBd
oneBbyBpalpatingBtheBcarotid,Bbrachial,BorBfemoralBarteryBwhileBobservingBtheBmonitorBforBw
idenedBcomplexesBorBbyBauscultatingBforBapicalBheartBsounds.BInBtheBsituationBofBacuteBMI,B
PVCsBmayBbeBconsideredBwarningBdysrhythmias,BpossiblyBheraldingBtheBonsetBofBventricularBt
achycardiaBorBventricularBfibrillation.BTherefore,BtheBnurseBwouldBnotBtellBtheBclientBthatBthe
BPVCsBareBexpected.BAlthoughBtheBnurseBwillBcontinueBtoBmonitorBtheBclientBandBdocument
BtheBfindings,BtheseBareBnotBtheBmostBappropriateBactionsBofBthoseBprovided.
NPOBstatusBisBimposedB8BhoursBbeforeBtheBprocedureBonBaBclientBscheduledBtoBundergoBele
ctroconvulsiveBtherapyB(ECT)BatB1Bp.m.BOnBtheBmorningBofBtheBprocedure,BtheBnurseBchecks
BtheBclient'sBrecordBandBnotesBthatBtheBclientBroutinelyBtakesBanBoralBantihypertensiveBmedi
cationBeachBmorning.BWhatBactionBshouldBtheBnurseBtake?
AdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
WithholdBtheBantihypertensiveBandBadministerBitBatBbedtime
AdministerBtheBmedicationBbyBwayBofBtheBintravenousB(IV)Broute
HoldBtheBantihypertensiveBandBresumeBitsBadministrationBonBtheBdayBafterBtheBECTB-
BAnswerAdministerBtheBantihypertensiveBwithBaBsmallBsipBofBwaterB
Rationale:BTheBnurseBshouldBadministerBtheBantihypertensiveBwithBaBsmallBsipBofBwater.BGen
eralBanesthesiaBisBrequiredBforBECT,BsoBNPOBstatusBisBimposedBforB6BtoB8BhoursBbeforeBtrea
tmentBtoBhelpBpreventBaspiration.BExceptionsBincludeBclientsBwhoBroutinelyBreceiveBcardiacBm
edications,BantihypertensiveBagents,BorBhistamineB(H2)Bblockers,BwhichBshouldBbeBadministere
dBseveralBhoursBbeforeBtreatmentBwithBaBsmallBsipBofBwater.BWithholdingBtheBantihypertensi
veBandBadministeringBitBatBbedtimeBandBwithholdingBtheBantihypertensiveBandBresumingBadm
inistrationBonBtheBdayBafterBtheBECTBareBincorrectBactions,BbecauseBantihypertensivesBmustBb
eBadministeredBonBtime;Botherwise,BtheBriskBforBreboundBhypertensionBexists.BTheBnurseBwo
uldBnotBadministerBaBmedicationBbyBwayBofBaBrouteBthatBhasBnotBbeenBprescribed.
ABclientBwhoBrecentlyBunderwentBcoronaryBarteryBbypassBgraftBsurgeryBcomesBtoBtheBprimar
yBhealthBcareBprovider'sBofficeBforBaBfollow-
upBvisit.BOnBassessment,BtheBclientBtellsBtheBnurseBthatBheBisBfeelingBdepressed.BWhichBresp
onseBbyBtheBnurseBisBtherapeutic?
"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
, "That'sBaBnormalBresponseBafterBthisBtypeBofBsurgery."
"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBthisBdepression."
"EveryBclientBwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth."B-
BAnswer"TellBmeBmoreBaboutBwhatByou'reBfeeling."B
Rationale:BTheBtherapeuticBresponseBbyBtheBnurseBis,B"TellBmeBmoreBaboutBwhatByou'reBfeeli
ng."BWhenBaBclientBexpressesBfeelingsBofBdepression,BitBisBextremelyBimportantBforBtheBnurs
eBtoBfurtherBexploreBtheseBfeelingsBwithBtheBclient.BInBstating,B"ThisBisBaBnormalBresponseBa
fterBthisBtypeBofBsurgery"BtheBnurseBprovidesBfalseBreassuranceBandBavoidsBaddressingBtheBcl
ient'sBfeelings.B"ItBwillBtakeBtime,BbutBIBpromiseByou,ByouBwillBgetBoverBtheBdepression"BisBa
lsoBaBfalseBreassurance,BandBitBdoesBnotBencourageBtheBexpressionBofBfeelings.B"EveryBclient
BwhoBhasBthisBsurgeryBfeelsBtheBsameBwayBforBaboutBaBmonth"BisBaBgeneralizationBthatBavo
idsBtheBclient'sBfeelings.
ABclientBinBlaborBexperiencesBspontaneousBruptureBofBtheBmembranes.BTheBnurseBimmediatel
yBcountsBtheBfetalBheartBrateB(FHR)BforB1BfullBminuteBandBthenBchecksBtheBamnioticBfluid.BT
heBnurseBnotesBthatBtheBfluidBisByellowBandBhasBaBstrongBodor.BWhichBactionBshouldBbeBth
eBnurse'sBpriority?
ContactBtheBprimaryBhealthBcareBproviderB
DocumentBtheBfindings
CheckBtheBfluidBforBprotein
ContinueBtoBmonitorBtheBclientBandBtheBFHRB-
BAnswerContactBtheBprimaryBhealthBcareBproviderB
Rationale:BTheBpriorityBactionBisBforBtheBnurseBtoBcontactBtheBprimaryBhealthBcareBprovider.B
TheBFHRBisBassessedBforBatBleastB1BminuteBwhenBtheBmembranesBrupture.BTheBnurseBalsoBc
hecksBtheBquantity,Bcolor,BandBodorBofBtheBamnioticBfluid.BTheBfluidBshouldBbeBclearB(oftenB
withBbitsBofBvernix)BandBhaveBaBmildBodor.BFluidBwithBaBfoulBorBstrongBodor,BcloudyBappear
ance,BorByellowBcolorationBsuggestsBchorioamnionitisBandBwarrantsBnotifyingBtheBprimaryBhea
lthBcareBprovider.BABlargeBamountBofBvernixBinBtheBfluidBsuggestsBthatBtheBfetusBisBpreterm.
BGreenish,Bmeconium-
stainedBfluidBmayBbeBseenBinBcasesBofBposttermBgestationBorBplacentalBinsufficiency.BCheckin
gBtheBfluidBforBproteinBisBnotBassociatedBwithBtheBdataBinBtheBquestion.BTheBnurseBwouldBc
ontinueBtoBmonitorBtheBclientBandBtheBFHRBandBwouldBdocumentBtheBfindings.
ABnurseBhasBassistedBaBprimaryBhealthBcareBproviderBinBinsertingBaBcentralBvenousBaccessBd
eviceBintoBaBclientBwithBaBdiagnosisBofBsevereBmalnutritionBwhoBwillBbeBreceivingBparenteral
BnutritionB(PN).BAfterBinsertionBofBtheBcatheterBwhatBdoesBtheBnurseBimmediatelyBdo?
