HESI: Periopera ve Care Ques ons and answers |
Updated | NEW | 2026
Which vital sign requires follow up by the nurse?
A. BP 160/80
B. Pulse of 68
C. Respiratory rate of 14
D. Temperature of 97.2 degrees F
A. BP 160/80
Ra,onale: This blood pressure is elevated and requires further ac,on by the nurse. All of the
other choices are within normal limits so they require nor further ac,on by the nurse.
The nurse reviews the medica,ons taken by Ms. Jackson. Ms. Jackson states that she has been
taking two medica,ons; Hydrochlorothiazide (Hydrodiuril), a diure,c, and warfarin (Coumadin),
an an,coagulant, everyday for more than one year. What nursing ac,on is most important?
A. Observe the appearance of the client's oral mucosa.
B. Assess the client for any signs of excessive bruising.
C. Review common side effects of each of the medica,ons.
D. Explain the need to withhold the warfarin prior to surgery.
D. Explain the need to withhold the warfarin prior to surgery.
Ra,onale: An,coagulants increase the risk for bleeding during surgery and the postopera,ve
period, so the nurse must explain the need to withhold warfarin prior to surgery and instruct
the client to contact the surgeon to determine how long before the surgery the medica,on
should be stopped. The other choices are relevant to the medica,ons she is taking but since the
client is receiving a an established daily dose for over a year, they are not the most important
preopera,ve interven,ons.
The nurse then reviews Ms. Jackson's preopera,ve lab results drawn earlier in the week. Which
serum lab value requires follow-up by the nurse?
A. Sodium of 135 mEq/L
B. WBC of 14,000/mm3
, C. Crea,nine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl
B. WBC of 14,000/mm3
Ra,onale: The normal WBC count is 5,000 to 10,000/mm3. An increase my indicate the onset of
an infec,on which may be a contraindica,on to surgery. The nurse should no,fy the surgeon of
this abnormal lab value.
The nurse talks to Ms. Jackson what to expect the day of the surgery and during the immediate
postopera,ve period. The nurse provide instruc,ons regarding cough and deep breathing
exercises. Ms. Jackson performs a return demonstra,on by breathing in deeply through her
mouth and exhaling forcefully and rapidly through pursed lips. Which ac,on should the nurse
implement?
A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough aAer taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful comple,on of the return demonstra,on.
C. Demonstrate the deep breathing and cough technique again.
Ra,onale: Ms. Jackson has demonstrated incorrect technique. When performing deep
breathing exercises, the client should inhale through the nose and exhale slowly through the
mouth without pursing the lips. The nurse should demonstrate the en,re procedure again for
best learning by the client.
When the nurse begins teaching the benefits of early mobiliza,on following surgery, Ms.
Jackson states, "Oh, I know if I stay in bed very long I will get bed sores." How should the nurse
respond?
A. "GeFng a bedsore is very serious. Some,mes people die from infected bedsores."
B. "The nurses will make sure you do not stay in bed long enough to get bedsores."
C. "Bedsores are one of the many problems that can occur from prolonged bedrest."
D. "Those are now called pressure ulcers, because they are caused by pressure."
C. "Bedsores are one of the many problems that can occur from prolonged bedrest."
Ra,onale: This response acknowledges the client's previous learning and promotes further
Updated | NEW | 2026
Which vital sign requires follow up by the nurse?
A. BP 160/80
B. Pulse of 68
C. Respiratory rate of 14
D. Temperature of 97.2 degrees F
A. BP 160/80
Ra,onale: This blood pressure is elevated and requires further ac,on by the nurse. All of the
other choices are within normal limits so they require nor further ac,on by the nurse.
The nurse reviews the medica,ons taken by Ms. Jackson. Ms. Jackson states that she has been
taking two medica,ons; Hydrochlorothiazide (Hydrodiuril), a diure,c, and warfarin (Coumadin),
an an,coagulant, everyday for more than one year. What nursing ac,on is most important?
A. Observe the appearance of the client's oral mucosa.
B. Assess the client for any signs of excessive bruising.
C. Review common side effects of each of the medica,ons.
D. Explain the need to withhold the warfarin prior to surgery.
D. Explain the need to withhold the warfarin prior to surgery.
Ra,onale: An,coagulants increase the risk for bleeding during surgery and the postopera,ve
period, so the nurse must explain the need to withhold warfarin prior to surgery and instruct
the client to contact the surgeon to determine how long before the surgery the medica,on
should be stopped. The other choices are relevant to the medica,ons she is taking but since the
client is receiving a an established daily dose for over a year, they are not the most important
preopera,ve interven,ons.
The nurse then reviews Ms. Jackson's preopera,ve lab results drawn earlier in the week. Which
serum lab value requires follow-up by the nurse?
A. Sodium of 135 mEq/L
B. WBC of 14,000/mm3
, C. Crea,nine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl
B. WBC of 14,000/mm3
Ra,onale: The normal WBC count is 5,000 to 10,000/mm3. An increase my indicate the onset of
an infec,on which may be a contraindica,on to surgery. The nurse should no,fy the surgeon of
this abnormal lab value.
The nurse talks to Ms. Jackson what to expect the day of the surgery and during the immediate
postopera,ve period. The nurse provide instruc,ons regarding cough and deep breathing
exercises. Ms. Jackson performs a return demonstra,on by breathing in deeply through her
mouth and exhaling forcefully and rapidly through pursed lips. Which ac,on should the nurse
implement?
A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough aAer taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful comple,on of the return demonstra,on.
C. Demonstrate the deep breathing and cough technique again.
Ra,onale: Ms. Jackson has demonstrated incorrect technique. When performing deep
breathing exercises, the client should inhale through the nose and exhale slowly through the
mouth without pursing the lips. The nurse should demonstrate the en,re procedure again for
best learning by the client.
When the nurse begins teaching the benefits of early mobiliza,on following surgery, Ms.
Jackson states, "Oh, I know if I stay in bed very long I will get bed sores." How should the nurse
respond?
A. "GeFng a bedsore is very serious. Some,mes people die from infected bedsores."
B. "The nurses will make sure you do not stay in bed long enough to get bedsores."
C. "Bedsores are one of the many problems that can occur from prolonged bedrest."
D. "Those are now called pressure ulcers, because they are caused by pressure."
C. "Bedsores are one of the many problems that can occur from prolonged bedrest."
Ra,onale: This response acknowledges the client's previous learning and promotes further
