Pathophysiology HESI Remediation
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1. The nurse is caring for a post-operative Administer IV fluids per protocol.
client who has a saline lock in place and
very little urine in the drainage bag. The client is showing signs of hypovolemic shock,
The client appears anxious and rest- a potential post-operative complication. The nurse
less. The nurse notes that the client's correctly treats this problem by infusing IV fluids
hands are cool and moist, and that the per protocol.
capillary refill is prolonged. Which ac-
tion should the nurse perform?
Offer the client a warm blanket.
Assess the client's breath sounds.
Administer IV fluids per protocol.
Review the client's medications.
2. When performing percussion of the Pleural effusion.
lungs, the nurse notes a dull sound in
the left lower chest. This finding may Percussion is used to assess pulmonary reso-
indicate the presence of which condi- nance. A dull sound indicates the presence of solid
tion? tissue, such as the liver in the right lower chest,
or an abnormal accumulation of fluid, such as an
Pneumothorax. effusion.
Pleural effusion.
Chronic bronchitis.
Emphysema.
3.
, Pathophysiology HESI Remediation
Study online at https://quizlet.com/_7oxwao
Which characteristic is typical of hyper- Development of a headache or blurred vision.
tensive crisis?
Hypertensive crisis involves elevated blood pres-
Clinical evidence of flatten jugular sure that can cause organ damage if the blood
vein. pressure is not brought down immediately. This
condition rarely occurs, often is a result of clients
Development of a headache or blurred not taking their hypertensive medications as pre-
vision. scribed.
Diastolic blood pressure less than 110
mm Hg.
Elevated cardiac enzymes.
4. The nurse is caring for a client with Assess the client's breath sounds.
a fractured left hip. During the admis-
sion assessment, the nurse notes pe- A client with a fractured hip is at an increased risk
techiae and an increased heart rate. for fat embolism syndrome (FES). The fat emboli
Which action should the nurse perform can travel throughout the circulatory system and
next? block capillaries (resulting in petechiae) or small
vessels supplying vital organs, including the lungs.
Observe the fracture site for ecchymo- The nurse should assess the client's breath sounds
sis. to determine if emboli have traveled to the client's
lungs.
Obtain the client's blood pressure.
Document the assessment findings.
Assess the client's breath sounds.
5. While assessing a pediatric client with Document the assessment findings.
cerebral palsy, the nurse notes that
Cerebral palsy is a permanent disorder that leads
, Pathophysiology HESI Remediation
Study online at https://quizlet.com/_7oxwao
the child feels rigid and has signifi- to abnormalities in movement, posture, and in
cant arching of the back. Which action some cases, intellectual functioning. Stiffness and
should the nurse take? arching of the back are normal findings in a client
with cerebral palsy. The nurse should document
Reposition the child to a lying position. the expected findings.
Review the child's medication history.
Document the assessment findings.
Report the findings to the child's par-
ents.
6. The nurse is assessing an adult client "Are you experiencing shortness of breath?"
for lung cancer. Which question should
the nurse include in the client inter- When assessing a client for lung cancer, the nurse
view? should ask if the client is experiencing shortness
of breath. Dyspnea is the most common symptom
"Are you coughing up yellow-green in clients with lung cancer.
mucus?"
"Do you have a history of night
sweats?"
"Are you experiencing shortness of
breath?"
"Have you experienced sudden crush-
ing chest pain?"
7. The emergency department nurse is Positive halo sign.
caring for a client with a severe head in-
A client with a severe head injury may be at risk
Study online at https://quizlet.com/_7oxwao
1. The nurse is caring for a post-operative Administer IV fluids per protocol.
client who has a saline lock in place and
very little urine in the drainage bag. The client is showing signs of hypovolemic shock,
The client appears anxious and rest- a potential post-operative complication. The nurse
less. The nurse notes that the client's correctly treats this problem by infusing IV fluids
hands are cool and moist, and that the per protocol.
capillary refill is prolonged. Which ac-
tion should the nurse perform?
Offer the client a warm blanket.
Assess the client's breath sounds.
Administer IV fluids per protocol.
Review the client's medications.
2. When performing percussion of the Pleural effusion.
lungs, the nurse notes a dull sound in
the left lower chest. This finding may Percussion is used to assess pulmonary reso-
indicate the presence of which condi- nance. A dull sound indicates the presence of solid
tion? tissue, such as the liver in the right lower chest,
or an abnormal accumulation of fluid, such as an
Pneumothorax. effusion.
Pleural effusion.
Chronic bronchitis.
Emphysema.
3.
, Pathophysiology HESI Remediation
Study online at https://quizlet.com/_7oxwao
Which characteristic is typical of hyper- Development of a headache or blurred vision.
tensive crisis?
Hypertensive crisis involves elevated blood pres-
Clinical evidence of flatten jugular sure that can cause organ damage if the blood
vein. pressure is not brought down immediately. This
condition rarely occurs, often is a result of clients
Development of a headache or blurred not taking their hypertensive medications as pre-
vision. scribed.
Diastolic blood pressure less than 110
mm Hg.
Elevated cardiac enzymes.
4. The nurse is caring for a client with Assess the client's breath sounds.
a fractured left hip. During the admis-
sion assessment, the nurse notes pe- A client with a fractured hip is at an increased risk
techiae and an increased heart rate. for fat embolism syndrome (FES). The fat emboli
Which action should the nurse perform can travel throughout the circulatory system and
next? block capillaries (resulting in petechiae) or small
vessels supplying vital organs, including the lungs.
Observe the fracture site for ecchymo- The nurse should assess the client's breath sounds
sis. to determine if emboli have traveled to the client's
lungs.
Obtain the client's blood pressure.
Document the assessment findings.
Assess the client's breath sounds.
5. While assessing a pediatric client with Document the assessment findings.
cerebral palsy, the nurse notes that
Cerebral palsy is a permanent disorder that leads
, Pathophysiology HESI Remediation
Study online at https://quizlet.com/_7oxwao
the child feels rigid and has signifi- to abnormalities in movement, posture, and in
cant arching of the back. Which action some cases, intellectual functioning. Stiffness and
should the nurse take? arching of the back are normal findings in a client
with cerebral palsy. The nurse should document
Reposition the child to a lying position. the expected findings.
Review the child's medication history.
Document the assessment findings.
Report the findings to the child's par-
ents.
6. The nurse is assessing an adult client "Are you experiencing shortness of breath?"
for lung cancer. Which question should
the nurse include in the client inter- When assessing a client for lung cancer, the nurse
view? should ask if the client is experiencing shortness
of breath. Dyspnea is the most common symptom
"Are you coughing up yellow-green in clients with lung cancer.
mucus?"
"Do you have a history of night
sweats?"
"Are you experiencing shortness of
breath?"
"Have you experienced sudden crush-
ing chest pain?"
7. The emergency department nurse is Positive halo sign.
caring for a client with a severe head in-
A client with a severe head injury may be at risk
