HESI: Perioperative Care Exam
Questions and Answers 100% Pass
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 - ANSWER-A. BP 160/80
Rationale: This blood pressure is elevated and requires further action by the nurse.
All of the other choices are within normal limits so they require nor further action
by the nurse.
The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states that
she has been taking two medications; Hydrochlorothiazide (Hydrodiuril), a
diuretic, and warfarin (Coumadin), an anticoagulant, everyday for more than one
year. What nursing action is most important?
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,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 medications.
D. Explain the need to withhold the warfarin prior to surgery. - ANSWER-D.
Explain the need to withhold the warfarin prior to surgery.
Rationale: Anticoagulants increase the risk for bleeding during surgery and the
postoperative 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 medication should be stopped. The other choices are
relevant to the medications she is taking but since the client is receiving a an
established daily dose for over a year, they are not the most important preoperative
interventions.
The nurse then reviews Ms. Jackson's preoperative 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
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, C. Creatinine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl - ANSWER-B. WBC of 14,000/mm3
Rationale: The normal WBC count is 5,000 to 10,000/mm3. An increase my
indicate the onset of an infection which may be a contraindication to surgery. The
nurse should notify 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 postoperative period. The nurse provide instructions regarding
cough and deep breathing exercises. Ms. Jackson performs a return demonstration
by breathing in deeply through her mouth and exhaling forcefully and rapidly
through pursed lips. Which action should the nurse implement?
A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough after taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful completion of the return demonstration. - ANSWER-C.
Demonstrate the deep breathing and cough technique again.
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Questions and Answers 100% Pass
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 - ANSWER-A. BP 160/80
Rationale: This blood pressure is elevated and requires further action by the nurse.
All of the other choices are within normal limits so they require nor further action
by the nurse.
The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states that
she has been taking two medications; Hydrochlorothiazide (Hydrodiuril), a
diuretic, and warfarin (Coumadin), an anticoagulant, everyday for more than one
year. What nursing action is most important?
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 1
,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 medications.
D. Explain the need to withhold the warfarin prior to surgery. - ANSWER-D.
Explain the need to withhold the warfarin prior to surgery.
Rationale: Anticoagulants increase the risk for bleeding during surgery and the
postoperative 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 medication should be stopped. The other choices are
relevant to the medications she is taking but since the client is receiving a an
established daily dose for over a year, they are not the most important preoperative
interventions.
The nurse then reviews Ms. Jackson's preoperative 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
©️COPYRIGHT 2025, ALL RIGHTS RESERVED. 2
, C. Creatinine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl - ANSWER-B. WBC of 14,000/mm3
Rationale: The normal WBC count is 5,000 to 10,000/mm3. An increase my
indicate the onset of an infection which may be a contraindication to surgery. The
nurse should notify 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 postoperative period. The nurse provide instructions regarding
cough and deep breathing exercises. Ms. Jackson performs a return demonstration
by breathing in deeply through her mouth and exhaling forcefully and rapidly
through pursed lips. Which action should the nurse implement?
A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough after taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful completion of the return demonstration. - ANSWER-C.
Demonstrate the deep breathing and cough technique again.
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