HESI CASE STUDIES FALL 2023 WITH
SOLUTIONS
The nurse reviews the client's medications. The client indicates that she has been taking two
medications; hydrochlorothiazide, a diuretic, and warfarin , an anticoagulant, every day for more than a
year.
Which vital sign requires follow-up by the nurse?
BP of 160/88 mmHg.
Pulse of 68 beats/min.
Respirations of 14 breaths/min.
Temperature of 97.2° F (36.2° C). - ✔✔BP of 160/88 mmHg.
This blood pressure is elevated and requires further action by the nurse.
What nursing action is most important?
Observe the appearance of the client's oral mucosa.
Assess the client for any signs of excessive bruising.
Review common side effects of each of the medications.
Explain the need to withhold the warfarin prior to surgery. - ✔✔Explain the need to withhold the
warfarin prior to surgery.
Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse
must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the
surgeon to determine how long before surgery the medication should be stopped.
,Which serum lab value requires follow-up by the nurse?
Sodium of 135 mEq/L (135 mmol/L).
WBC of 14,000/μL (4.0 x 109/L).
Creatinine of 0.7 mg/dl (61.9 mmol/L).
Hemoglobin of 14 g/dL (140 g/L). - ✔✔WBC of 14,000/μL (4.0 x 109/L).
The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the onset of an
infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this
abnormal lab value.
Preoperative Teaching
The nurse talks with the client about what to expect the day of surgery and during the immediate
postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. The
client performs a return demonstration by breathing in deeply through their mouth and exhaling
forcefully and rapidly through pursed lips.
What action should the nurse implement?
Advise the client to avoid pursing her lips when exhaling.
Remind the client to cough after taking 2 to 3 breaths.
Demonstrate the deep breathing and coughing technique again.
Document successful completion of the return demonstration. - ✔✔Demonstrate the deep breathing
and coughing technique again.
The client 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 entire procedure again for best learning by the client.
When the nurse begins teaching about the benefits of early mobilization following surgery, the client
states, "Oh, I know if I stay in bed very long I will get bedsores."
,How should the nurse respond?
"Getting a bedsore is very serious. Sometimes people die from infected bedsores."
"The nurses will make sure you do not stay in bed long enough to get bedsores."
"Bedsores are one of many problems that can occur from prolonged bedrest."
"Those are now called pressure ulcers because they are caused by pressure." - ✔✔"Bedsores are one of
many problems that can occur from prolonged bedrest."
This response acknowledges the client's previous learning and promotes further learning related to
other complications of immobility such as thrombus formation, constipation, and atelectasis.
The nurse discusses postoperative pain management with the client and explains the use of a patient-
controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself,
since they will be sleepy after surgery.
How should the nurse respond?
"You will only use the PCA pump for the first 24 hours after surgery."
"The surgeon will prescribe the dose of medication that is correct for you."
"I will tell the surgeon that you prefer that the nurses administer your pain medicine."
"The pump has a control device that prevents you from taking too much medicine." - ✔✔The pump has
a control device that prevents you from taking too much medicine."
This response provides the client with the information needed to understand that she cannot overdose
herself while she is sedated after surgery.
Therapeutic Communication
While discussing postoperative pain management strategies with the client, the nurse observes them
begin to cry.
, What action should the nurse take?
Quietly sit with the client.
Offer reassurance about the surgery.
Calmly continue the preoperative instructions.
Leave the room until the client has composed herself. - ✔✔Quietly sit with the client.
Offering one's presence is a caring and therapeutic response.
After the client stops crying, she states, "My father was in so much pain before he died. Talking about
pain brings back so many memories."
How should the nurse respond?
"We do not need to talk about pain control today if it makes you sad."
"Perhaps you need to see a counselor to help you resolve your grief."
"It sounds as if you went through a difficult time when your father died."
"You need to focus on your own needs now and not on past memories." - ✔✔"It sounds as if you went
through a difficult time when your father died."
This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for
further discussion by the client if desired.
Surgical Preparation
The next week, the client arrives at the surgery center 3 hours before their scheduled surgery.
SOLUTIONS
The nurse reviews the client's medications. The client indicates that she has been taking two
medications; hydrochlorothiazide, a diuretic, and warfarin , an anticoagulant, every day for more than a
year.
Which vital sign requires follow-up by the nurse?
BP of 160/88 mmHg.
Pulse of 68 beats/min.
Respirations of 14 breaths/min.
Temperature of 97.2° F (36.2° C). - ✔✔BP of 160/88 mmHg.
This blood pressure is elevated and requires further action by the nurse.
What nursing action is most important?
Observe the appearance of the client's oral mucosa.
Assess the client for any signs of excessive bruising.
Review common side effects of each of the medications.
Explain the need to withhold the warfarin prior to surgery. - ✔✔Explain the need to withhold the
warfarin prior to surgery.
Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse
must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the
surgeon to determine how long before surgery the medication should be stopped.
,Which serum lab value requires follow-up by the nurse?
Sodium of 135 mEq/L (135 mmol/L).
WBC of 14,000/μL (4.0 x 109/L).
Creatinine of 0.7 mg/dl (61.9 mmol/L).
Hemoglobin of 14 g/dL (140 g/L). - ✔✔WBC of 14,000/μL (4.0 x 109/L).
The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the onset of an
infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this
abnormal lab value.
Preoperative Teaching
The nurse talks with the client about what to expect the day of surgery and during the immediate
postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. The
client performs a return demonstration by breathing in deeply through their mouth and exhaling
forcefully and rapidly through pursed lips.
What action should the nurse implement?
Advise the client to avoid pursing her lips when exhaling.
Remind the client to cough after taking 2 to 3 breaths.
Demonstrate the deep breathing and coughing technique again.
Document successful completion of the return demonstration. - ✔✔Demonstrate the deep breathing
and coughing technique again.
The client 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 entire procedure again for best learning by the client.
When the nurse begins teaching about the benefits of early mobilization following surgery, the client
states, "Oh, I know if I stay in bed very long I will get bedsores."
,How should the nurse respond?
"Getting a bedsore is very serious. Sometimes people die from infected bedsores."
"The nurses will make sure you do not stay in bed long enough to get bedsores."
"Bedsores are one of many problems that can occur from prolonged bedrest."
"Those are now called pressure ulcers because they are caused by pressure." - ✔✔"Bedsores are one of
many problems that can occur from prolonged bedrest."
This response acknowledges the client's previous learning and promotes further learning related to
other complications of immobility such as thrombus formation, constipation, and atelectasis.
The nurse discusses postoperative pain management with the client and explains the use of a patient-
controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself,
since they will be sleepy after surgery.
How should the nurse respond?
"You will only use the PCA pump for the first 24 hours after surgery."
"The surgeon will prescribe the dose of medication that is correct for you."
"I will tell the surgeon that you prefer that the nurses administer your pain medicine."
"The pump has a control device that prevents you from taking too much medicine." - ✔✔The pump has
a control device that prevents you from taking too much medicine."
This response provides the client with the information needed to understand that she cannot overdose
herself while she is sedated after surgery.
Therapeutic Communication
While discussing postoperative pain management strategies with the client, the nurse observes them
begin to cry.
, What action should the nurse take?
Quietly sit with the client.
Offer reassurance about the surgery.
Calmly continue the preoperative instructions.
Leave the room until the client has composed herself. - ✔✔Quietly sit with the client.
Offering one's presence is a caring and therapeutic response.
After the client stops crying, she states, "My father was in so much pain before he died. Talking about
pain brings back so many memories."
How should the nurse respond?
"We do not need to talk about pain control today if it makes you sad."
"Perhaps you need to see a counselor to help you resolve your grief."
"It sounds as if you went through a difficult time when your father died."
"You need to focus on your own needs now and not on past memories." - ✔✔"It sounds as if you went
through a difficult time when your father died."
This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for
further discussion by the client if desired.
Surgical Preparation
The next week, the client arrives at the surgery center 3 hours before their scheduled surgery.
