HESI 700 QUESTIONS AND ANSWERS
WITH SOLUTIONS 2024
FollowingGdischargeGteaching,GaGmaleGclientGwithGduodenalGulcerGtellsGtheGnurseGtheGheGwillGdrinkGplentyG
ofGdairyGproducts,GsuchGasGmilk,GtoGhelpGcoatGandGprotectGhisGulcer.GWhatGisGtheGbestGfollow-
upGactionGbyGtheGnurse?G-
GANSWERGReviewGwithGtheGclientGtheGneedGtoGavoidGfoodsGthatGareGrichGinGmilkGandGcream
AGmaleGclientGwithGhypertension,GwhoGreceivedGnewGantihypertensiveGprescriptionsGatGhisGlastGvisitGretur
nsGtoGtheGclinicGtwoGweeksGlaterGtoGevaluateGhisGbloodGpressureG(BP).GHisGBPGisG158/106GandGheGadmitsGt
hatGheGhasGnotGbeenGtakingGtheGprescribedGmedicationGbecauseGtheGdrugsGmakeGhimG"feelGbad".GInGexpla
iningGtheGneedGforGhypertensionGcontrol,GtheGnurseGshouldGstressGthatGanGelevatedGBPGplacesGtheGclientGa
tGriskGforGwhichGpathophysiologicalGcondition?G-GANSWERGStrokeGsecondaryGtoGhemorrhage
TheGnurseGobservesGanGunlicensedGassistiveGpersonnelG(UAP)GpositioningGaGnewlyGadmittedGclientGwhoGh
asGaGseizureGdisorder.GTheGclientGisGsupineGandGtheGUAPGisGplacingGsoftGpillowsGalongGtheGsideGrails.GWhatG
actionGshouldGtheGnurseGimplement?G-
GANSWERGInstructGtheGUAPGtoGobtainGsoftGblanketsGtoGsecureGtoGtheGsideGrailsGinsteadGofGpillows
AnGadolescentGwithGmajorGdepressiveGdisorderGhasGbeenGtakingGduloxetineG(Cymbalta)GforGtheGpastG12Gd
ays.GWhichGassessmentGfindingGrequiresGimmediateGfollow-upG-GANSWERGDescribesGlifeGwithoutGpurpose
AG60-year-
oldGfemaleGclientGwithGaGpositiveGfamilyGhistoryGofGovarianGcancerGhasGdevelopedGanGabdominalGmassGan
dGisGbeingGevaluatedGforGpossibleGovarianGcancer.GHerGPapanicolauG(Pap)GsmearGresultsGareGnegative.GWh
atGinformationGshouldGtheGnurseGincludeGinGtheGclient'sGteachingGplanG-
GANSWERGFurtherGevaluationGinvolvingGsurgeryGmayGbeGneeded
AGclientGwhoGrecentlyGunderwentGaGtracheostomyGisGbeingGpreparedGforGdischargeGtoGhome.GWhichGinstr
uctionsGisGmostGimportantGforGtheGnurseGtoGincludeGinGtheGdischargeGplan?G-
GANSWERGTeachGtrachealGsuctioningGtechniques
InGassessingGanGadultGclientGwithGaGpartialGrebreatherGmask,GtheGnurseGnotesGthatGtheGoxygenGreservoirGb
agGdoesGnotGdeflateGcompletelyGduringGinspirationGandGtheGclient'sGrespiratoryGrateGisG14GbreathsG/Gminut
e.GWhatGactionGshouldGtheGnurseGimplementG-GANSWERGDocumentGtheGassessmentGdataG
,Rational:GreservoirGbagGshouldGnotGdeflateGcompletelyGduringGinspirationGandGtheGclient'sGrespiratoryGrat
eGisGwithinGnormalGlimits.
DuringGshiftGreport,GtheGcentralGelectrocardiogramG(EKG)GmonitoringGsystemGalarms.GWhichGclientGalarmG
shouldGtheGnurseGinvestigateGfirst?G-GANSWERGRespiratoryGapneaGofG30Gseconds
DuringGaGhomeGvisit,GtheGnurseGobservedGanGelderlyGclientGwithGdiabetesGslipGandGfall.GWhatGactionGshoul
dGtheGnurseGtakeGfirst?G-GANSWERGCheckGtheGclientGforGlacerationsGorGfractures
AtG0600GwhileGadmittingGaGwomanGforGaGscheduleGrepeatGcesareanGsectionG(C-
Section),GtheGclientGtellsGtheGnurseGthatGsheGdrankGaGcupGaGcoffeeGatG0400GbecauseGsheGwantedGtoGavoidG
gettingGaGheadache.GWhichGactionGshouldGtheGnurseGtakeGfirst?G-
GANSWERGInformGtheGanesthesiaGcareGprovider
AfterGplacingGaGstethoscopeGasGseenGinGtheGpicture,GtheGnurseGauscultatesGS1GandGS2GheartGsounds.GToGde
termineGifGanGS3GheartGsoundGisGpresent,GwhatGactionGshouldGtheGnurseGtakeGfirstG-
GANSWERGListenGwithGtheGbellGatGtheGsameGlocation
AG66-year-
oldGwomanGisGretiringGandGwillGnoGlongerGhaveGaGhealthGinsuranceGthroughGherGplaceGofGemployment.GW
hichGagencyGshouldGtheGclientGbeGreferredGtoGbyGtheGemployeeGhealthGnurseGforGhealthGinsuranceGneeds?
G-GANSWERGMedicare
AGclientGwhoGisGtakingGanGoralGdoseGofGaGtetracyclineGcomplainsGofGgastrointestinalGupset.GWhatGsnackGsh
ouldGtheGnurseGinstructGtheGclientGtoGtakeGwithGtheGtetracycline?G-
GANSWERGToastedGwheatGbreadGandGjelly
FollowingGaGlumbarGpuncture,GaGclientGvoicesGseveralGcomplaints.GWhatGcomplaintGindicatedGtoGtheGnurse
GthatGtheGclientGisGexperiencingGaGcomplication?G-
GANSWERG"IGhaveGaGheadacheGthatGgetsGworseGwhenGIGsitGup"
AnGelderlyGclientGseemsGconfusedGandGreportsGtheGonsetGofGnausea,Gdysuria,GandGurgencyGwithGincontine
nce.GWhichGactionGshouldGtheGnurseGimplementG-GANSWERGObtainGaGcleanGcatchGmid-streamGspecimen
,TheGnurseGisGassistingGtheGmotherGofGaGchildGwithGphenylketonuriaG(PKU)GtoGselectGfoodsGthatGareGinGkeep
ingGwithGtheGchild'sGdietaryGrestrictions.GWhichGfoodsGareGcontraindicatedGforGthisGchild?G-
GANSWERGFoodsGsweetenedGwithGaspartame
BeforeGpreparingGaGclientGforGtheGfirstGsurgicalGcaseGofGtheGday,GaGpart-
timeGscrubGnurseGasksGtheGcirculatingGnurseGifGaG3GminuteGsurgicalGhandGscrubGisGadequateGpreparationGf
orGthisGclient.GWhichGresponseGshouldGtheGcirculatingGnurseGprovide?G-
GANSWERGDirectGtheGnurseGtoGcontinueGtheGsurgicalGhandGscrubGforGaG5GminuteGduration
WhichGbreakfastGselectionGindicatesGthatGtheGclientGunderstandsGtheGnurse'sGinstructionsGaboutGtheGdieta
ryGmanagementGofGosteoporosis?G-GANSWERGBagelGwithGjellyGandGskimGmilk
TheGchargeGnurseGofGaGcriticalGcareGunitGisGinformedGatGtheGbeginningGofGtheGshiftGthatGlessGthanGtheGopti
malGnumberGofGregisteredGnursesGwillGbeGworkingGthatGshift.GInGplanningGassignments,GwhichGclientGshoul
dGreceiveGtheGmostGcareGhoursGbyGaGregisteredGnurseG(RN)G-GANSWERGAnG82-year-
oldGclientGwithGAlzheimer'sGdiseaseGnewly-
fracturesGfemurGwhoGhasGaGFoleyGcatheterGandGsoftGwristGrestrainsGapplied
AGmotherGbringsGherG6-year-
oldGchild,GwhoGhasGjustGsteppedGonGaGrustyGnail,GtoGtheGpediatrician'sGoffice.GUponGinspection,GtheGnurseG
notesGthatGtheGnailGwentGthroughGtheGshoeGandGpiercedGtheGbottomGofGtheGchild'sGfoot.GWhichGactionGsh
ouldGtheGnurseGimplementGfirst?G-
GANSWERGCleanseGtheGfootGwithGsoapGandGwaterGandGapplyGanGantibioticGointment
TheGmotherGofGanGadolescentGtellsGtheGclinicGnurse,G"MyGsonGhasGathlete'sGfoot,GIGhaveGbeenGapplyingGtri
pleGantibioticGointmentGforGtwoGdays,GbutGthereGhasGbeenGnoGimprovement."GWhatGinstructionGshouldGth
eGnurseGprovide?G-
GANSWERGStopGusingGtheGointmentGandGencourageGcompleteGdryingGofGtheGfeetGandGwearingGcleanGsocks
.
AG26-year-
oldGfemaleGclientGisGadmittedGtoGtheGhospitalGforGtreatmentGofGaGsimpleGgoiter,GandGlevothyroxineGsodium
G(Synthroid)GisGprescribed.GWhichGsymptomsGindicateGtoGtheGnurseGthatGtheGprescribedGdosageGisGtooGhig
hGforGthisGclient?GTheGclientGexperiencesG-GANSWERGPalpitationsGandGshortnessGofGbreath
, AGclientGwithGaGhistoryGofGheartGfailureGpresentsGtoGtheGclinicGwithGaGnausea,Gvomiting,GyellowGvisionGandG
palpitations.GWhichGfindingGisGmostGimportantGforGtheGnurseGtoGassessGtoGtheGclient?G-
GANSWERGObtainGaGlistGofGmedicationsGtakenGforGcardiacGhistory
TheGhealthcareGproviderGprescribesGanGIVGsolutionGofGisoproterenolG(Isuprel)G1GmgGinG250GmlGofGD5WGatG
300Gmcg/hour.GTheGnurseGshouldGprogramGtheGinfusionGpumpGtoGdeliverGhowGmanyGml/hour?G(EnterGnu
mericGvalueGonly.)G-GANSWERG75G
Rationale:GConvertGmgGtoGmcgGandGuseGtheGformulaGD/HGxGQ.G300Gmcg/hourG/G1,000GmcgGxG250GmlG=G3/1
GxG25G=G75Gml/hour
TheGpathophysiologicalGmechanismGareGresponsibleGforGascitesGrelatedGtoGliverGfailure?G(SelectGallGthatGap
ply)G-GANSWERG-FluidGshiftsGfromGintravascularGtoGinterstitialGareaGdueGtoGdecreasedGserumGproteinG
-IncreasedGhydrostaticGpressureGinGportalGcirculationGincreasesGfluidGshiftsGintoGabdomenG
-IncreasedGcirculatingGaldosteroneGlevelsGthatGincreaseGsodiumGandGwaterGretention
TheGnurseGisGauscultatingGaGclient'sGheartGsounds.GWhichGdescriptionGshouldGtheGnurseGuseGtoGdocumentG
thisGsound?G(PleaseGlistenGtoGtheGaudioGfirstGtoGselectGtheGoptionGthatGapplies)G-GANSWERGMurmur
TheGhealthcareGproviderGprescribesGceltazidimeG(Fortax)G35GmgGeveryG8GhoursGIMGforGanGinfant.GTheG500G
mgGvialGisGlabeledGwithGtheGinstructionGtoGaddG5.3GmlGdiluentGtoGprovideGaGconcentrationGofG100Gmg/ml.G
HowGmanyGmlGshouldGtheGnurseGadministeredGforGeachGdose?G(EnterGnumericGvalueGonly.GIfGroundingGisGr
equired,GroundGtoGtheGnearestGtenthG-GANSWERG0.4G
rationale:G35mg/100mgGxG1G=G0.35G=G0.4Gml
TheGnurseGnotesGthatGaGclientGhasGbeenGreceivingGhydromorphoneG(Dilaudid)GeveryGsixGhoursGforGfourGda
ys.GWhatGassessmentGisGmostGimportantGforGtheGnurseGtoGcomplete?G-
GANSWERGAuscultateGtheGclient'sGbowelGsounds
Rationale:GhydromorphoneGisGaGpotentGopioidGanalgesicGthatGslowsGperistalsisGandGfrequentlyGcausesGcon
stipation,GsoGitGisGmostGimportantGtoGAuscultateGtheGclient'sGbowelGsounds
AGfemaleGclientGisGadmittedGwithGendGstageGpulmonaryGdiseaseGisGalert,Goriented,GandGcomplainingGofGsh
ortnessGofGbreath.GTheGclientGtellsGtheGnurseGthatGsheGwantsG"noGheroicGmeasures"GtakenGifGsheGstopsGbre
athing,GandGsheGasksGtheGnurseGtoGdocumentGthisGinGherGmedicalGrecord.GWhatGactionGshouldGtheGnurseGi
mplementG-GANSWERGAskGtheGclientGtoGdiscussG"doGnotGresuscitate"GwithGherGhealthcareGprovider
WITH SOLUTIONS 2024
FollowingGdischargeGteaching,GaGmaleGclientGwithGduodenalGulcerGtellsGtheGnurseGtheGheGwillGdrinkGplentyG
ofGdairyGproducts,GsuchGasGmilk,GtoGhelpGcoatGandGprotectGhisGulcer.GWhatGisGtheGbestGfollow-
upGactionGbyGtheGnurse?G-
GANSWERGReviewGwithGtheGclientGtheGneedGtoGavoidGfoodsGthatGareGrichGinGmilkGandGcream
AGmaleGclientGwithGhypertension,GwhoGreceivedGnewGantihypertensiveGprescriptionsGatGhisGlastGvisitGretur
nsGtoGtheGclinicGtwoGweeksGlaterGtoGevaluateGhisGbloodGpressureG(BP).GHisGBPGisG158/106GandGheGadmitsGt
hatGheGhasGnotGbeenGtakingGtheGprescribedGmedicationGbecauseGtheGdrugsGmakeGhimG"feelGbad".GInGexpla
iningGtheGneedGforGhypertensionGcontrol,GtheGnurseGshouldGstressGthatGanGelevatedGBPGplacesGtheGclientGa
tGriskGforGwhichGpathophysiologicalGcondition?G-GANSWERGStrokeGsecondaryGtoGhemorrhage
TheGnurseGobservesGanGunlicensedGassistiveGpersonnelG(UAP)GpositioningGaGnewlyGadmittedGclientGwhoGh
asGaGseizureGdisorder.GTheGclientGisGsupineGandGtheGUAPGisGplacingGsoftGpillowsGalongGtheGsideGrails.GWhatG
actionGshouldGtheGnurseGimplement?G-
GANSWERGInstructGtheGUAPGtoGobtainGsoftGblanketsGtoGsecureGtoGtheGsideGrailsGinsteadGofGpillows
AnGadolescentGwithGmajorGdepressiveGdisorderGhasGbeenGtakingGduloxetineG(Cymbalta)GforGtheGpastG12Gd
ays.GWhichGassessmentGfindingGrequiresGimmediateGfollow-upG-GANSWERGDescribesGlifeGwithoutGpurpose
AG60-year-
oldGfemaleGclientGwithGaGpositiveGfamilyGhistoryGofGovarianGcancerGhasGdevelopedGanGabdominalGmassGan
dGisGbeingGevaluatedGforGpossibleGovarianGcancer.GHerGPapanicolauG(Pap)GsmearGresultsGareGnegative.GWh
atGinformationGshouldGtheGnurseGincludeGinGtheGclient'sGteachingGplanG-
GANSWERGFurtherGevaluationGinvolvingGsurgeryGmayGbeGneeded
AGclientGwhoGrecentlyGunderwentGaGtracheostomyGisGbeingGpreparedGforGdischargeGtoGhome.GWhichGinstr
uctionsGisGmostGimportantGforGtheGnurseGtoGincludeGinGtheGdischargeGplan?G-
GANSWERGTeachGtrachealGsuctioningGtechniques
InGassessingGanGadultGclientGwithGaGpartialGrebreatherGmask,GtheGnurseGnotesGthatGtheGoxygenGreservoirGb
agGdoesGnotGdeflateGcompletelyGduringGinspirationGandGtheGclient'sGrespiratoryGrateGisG14GbreathsG/Gminut
e.GWhatGactionGshouldGtheGnurseGimplementG-GANSWERGDocumentGtheGassessmentGdataG
,Rational:GreservoirGbagGshouldGnotGdeflateGcompletelyGduringGinspirationGandGtheGclient'sGrespiratoryGrat
eGisGwithinGnormalGlimits.
DuringGshiftGreport,GtheGcentralGelectrocardiogramG(EKG)GmonitoringGsystemGalarms.GWhichGclientGalarmG
shouldGtheGnurseGinvestigateGfirst?G-GANSWERGRespiratoryGapneaGofG30Gseconds
DuringGaGhomeGvisit,GtheGnurseGobservedGanGelderlyGclientGwithGdiabetesGslipGandGfall.GWhatGactionGshoul
dGtheGnurseGtakeGfirst?G-GANSWERGCheckGtheGclientGforGlacerationsGorGfractures
AtG0600GwhileGadmittingGaGwomanGforGaGscheduleGrepeatGcesareanGsectionG(C-
Section),GtheGclientGtellsGtheGnurseGthatGsheGdrankGaGcupGaGcoffeeGatG0400GbecauseGsheGwantedGtoGavoidG
gettingGaGheadache.GWhichGactionGshouldGtheGnurseGtakeGfirst?G-
GANSWERGInformGtheGanesthesiaGcareGprovider
AfterGplacingGaGstethoscopeGasGseenGinGtheGpicture,GtheGnurseGauscultatesGS1GandGS2GheartGsounds.GToGde
termineGifGanGS3GheartGsoundGisGpresent,GwhatGactionGshouldGtheGnurseGtakeGfirstG-
GANSWERGListenGwithGtheGbellGatGtheGsameGlocation
AG66-year-
oldGwomanGisGretiringGandGwillGnoGlongerGhaveGaGhealthGinsuranceGthroughGherGplaceGofGemployment.GW
hichGagencyGshouldGtheGclientGbeGreferredGtoGbyGtheGemployeeGhealthGnurseGforGhealthGinsuranceGneeds?
G-GANSWERGMedicare
AGclientGwhoGisGtakingGanGoralGdoseGofGaGtetracyclineGcomplainsGofGgastrointestinalGupset.GWhatGsnackGsh
ouldGtheGnurseGinstructGtheGclientGtoGtakeGwithGtheGtetracycline?G-
GANSWERGToastedGwheatGbreadGandGjelly
FollowingGaGlumbarGpuncture,GaGclientGvoicesGseveralGcomplaints.GWhatGcomplaintGindicatedGtoGtheGnurse
GthatGtheGclientGisGexperiencingGaGcomplication?G-
GANSWERG"IGhaveGaGheadacheGthatGgetsGworseGwhenGIGsitGup"
AnGelderlyGclientGseemsGconfusedGandGreportsGtheGonsetGofGnausea,Gdysuria,GandGurgencyGwithGincontine
nce.GWhichGactionGshouldGtheGnurseGimplementG-GANSWERGObtainGaGcleanGcatchGmid-streamGspecimen
,TheGnurseGisGassistingGtheGmotherGofGaGchildGwithGphenylketonuriaG(PKU)GtoGselectGfoodsGthatGareGinGkeep
ingGwithGtheGchild'sGdietaryGrestrictions.GWhichGfoodsGareGcontraindicatedGforGthisGchild?G-
GANSWERGFoodsGsweetenedGwithGaspartame
BeforeGpreparingGaGclientGforGtheGfirstGsurgicalGcaseGofGtheGday,GaGpart-
timeGscrubGnurseGasksGtheGcirculatingGnurseGifGaG3GminuteGsurgicalGhandGscrubGisGadequateGpreparationGf
orGthisGclient.GWhichGresponseGshouldGtheGcirculatingGnurseGprovide?G-
GANSWERGDirectGtheGnurseGtoGcontinueGtheGsurgicalGhandGscrubGforGaG5GminuteGduration
WhichGbreakfastGselectionGindicatesGthatGtheGclientGunderstandsGtheGnurse'sGinstructionsGaboutGtheGdieta
ryGmanagementGofGosteoporosis?G-GANSWERGBagelGwithGjellyGandGskimGmilk
TheGchargeGnurseGofGaGcriticalGcareGunitGisGinformedGatGtheGbeginningGofGtheGshiftGthatGlessGthanGtheGopti
malGnumberGofGregisteredGnursesGwillGbeGworkingGthatGshift.GInGplanningGassignments,GwhichGclientGshoul
dGreceiveGtheGmostGcareGhoursGbyGaGregisteredGnurseG(RN)G-GANSWERGAnG82-year-
oldGclientGwithGAlzheimer'sGdiseaseGnewly-
fracturesGfemurGwhoGhasGaGFoleyGcatheterGandGsoftGwristGrestrainsGapplied
AGmotherGbringsGherG6-year-
oldGchild,GwhoGhasGjustGsteppedGonGaGrustyGnail,GtoGtheGpediatrician'sGoffice.GUponGinspection,GtheGnurseG
notesGthatGtheGnailGwentGthroughGtheGshoeGandGpiercedGtheGbottomGofGtheGchild'sGfoot.GWhichGactionGsh
ouldGtheGnurseGimplementGfirst?G-
GANSWERGCleanseGtheGfootGwithGsoapGandGwaterGandGapplyGanGantibioticGointment
TheGmotherGofGanGadolescentGtellsGtheGclinicGnurse,G"MyGsonGhasGathlete'sGfoot,GIGhaveGbeenGapplyingGtri
pleGantibioticGointmentGforGtwoGdays,GbutGthereGhasGbeenGnoGimprovement."GWhatGinstructionGshouldGth
eGnurseGprovide?G-
GANSWERGStopGusingGtheGointmentGandGencourageGcompleteGdryingGofGtheGfeetGandGwearingGcleanGsocks
.
AG26-year-
oldGfemaleGclientGisGadmittedGtoGtheGhospitalGforGtreatmentGofGaGsimpleGgoiter,GandGlevothyroxineGsodium
G(Synthroid)GisGprescribed.GWhichGsymptomsGindicateGtoGtheGnurseGthatGtheGprescribedGdosageGisGtooGhig
hGforGthisGclient?GTheGclientGexperiencesG-GANSWERGPalpitationsGandGshortnessGofGbreath
, AGclientGwithGaGhistoryGofGheartGfailureGpresentsGtoGtheGclinicGwithGaGnausea,Gvomiting,GyellowGvisionGandG
palpitations.GWhichGfindingGisGmostGimportantGforGtheGnurseGtoGassessGtoGtheGclient?G-
GANSWERGObtainGaGlistGofGmedicationsGtakenGforGcardiacGhistory
TheGhealthcareGproviderGprescribesGanGIVGsolutionGofGisoproterenolG(Isuprel)G1GmgGinG250GmlGofGD5WGatG
300Gmcg/hour.GTheGnurseGshouldGprogramGtheGinfusionGpumpGtoGdeliverGhowGmanyGml/hour?G(EnterGnu
mericGvalueGonly.)G-GANSWERG75G
Rationale:GConvertGmgGtoGmcgGandGuseGtheGformulaGD/HGxGQ.G300Gmcg/hourG/G1,000GmcgGxG250GmlG=G3/1
GxG25G=G75Gml/hour
TheGpathophysiologicalGmechanismGareGresponsibleGforGascitesGrelatedGtoGliverGfailure?G(SelectGallGthatGap
ply)G-GANSWERG-FluidGshiftsGfromGintravascularGtoGinterstitialGareaGdueGtoGdecreasedGserumGproteinG
-IncreasedGhydrostaticGpressureGinGportalGcirculationGincreasesGfluidGshiftsGintoGabdomenG
-IncreasedGcirculatingGaldosteroneGlevelsGthatGincreaseGsodiumGandGwaterGretention
TheGnurseGisGauscultatingGaGclient'sGheartGsounds.GWhichGdescriptionGshouldGtheGnurseGuseGtoGdocumentG
thisGsound?G(PleaseGlistenGtoGtheGaudioGfirstGtoGselectGtheGoptionGthatGapplies)G-GANSWERGMurmur
TheGhealthcareGproviderGprescribesGceltazidimeG(Fortax)G35GmgGeveryG8GhoursGIMGforGanGinfant.GTheG500G
mgGvialGisGlabeledGwithGtheGinstructionGtoGaddG5.3GmlGdiluentGtoGprovideGaGconcentrationGofG100Gmg/ml.G
HowGmanyGmlGshouldGtheGnurseGadministeredGforGeachGdose?G(EnterGnumericGvalueGonly.GIfGroundingGisGr
equired,GroundGtoGtheGnearestGtenthG-GANSWERG0.4G
rationale:G35mg/100mgGxG1G=G0.35G=G0.4Gml
TheGnurseGnotesGthatGaGclientGhasGbeenGreceivingGhydromorphoneG(Dilaudid)GeveryGsixGhoursGforGfourGda
ys.GWhatGassessmentGisGmostGimportantGforGtheGnurseGtoGcomplete?G-
GANSWERGAuscultateGtheGclient'sGbowelGsounds
Rationale:GhydromorphoneGisGaGpotentGopioidGanalgesicGthatGslowsGperistalsisGandGfrequentlyGcausesGcon
stipation,GsoGitGisGmostGimportantGtoGAuscultateGtheGclient'sGbowelGsounds
AGfemaleGclientGisGadmittedGwithGendGstageGpulmonaryGdiseaseGisGalert,Goriented,GandGcomplainingGofGsh
ortnessGofGbreath.GTheGclientGtellsGtheGnurseGthatGsheGwantsG"noGheroicGmeasures"GtakenGifGsheGstopsGbre
athing,GandGsheGasksGtheGnurseGtoGdocumentGthisGinGherGmedicalGrecord.GWhatGactionGshouldGtheGnurseGi
mplementG-GANSWERGAskGtheGclientGtoGdiscussG"doGnotGresuscitate"GwithGherGhealthcareGprovider
