NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
1.ID:G9476788675
EnalaprilG maleateG isG prescribedG forG aG hospitalizedG client.G WhichG assessmentG d
oesGtheGnurseGperformGasGaGpriorityG beforeGadministeringG theGmedication?
A. CheckingGtheGclient'sGbloodGpressur Correct
e
B. CheckingG theG client'sG peripheralG pulses
C. G GGGG CheckingGtheGmostGrecentGpotassiumGlevel
D. CheckingGtheGclient'sGintake-and-
G GG
outputGrecordGforGtheG lastG24GhoursGIncorrect
Rationale:G EnalaprilG maleateG isG anG angiotensin-
convertingG enzymeG (ACE)G inhibitorGusedGtoGtreatGhypertension.GOneGcommonGsideGe
ffectGisGposturalGhypotension.
ThereforeGtheGnurseGwouldGcheckGtheGclient’sGbloodGpressureGimmediatelyGbeforeGa
dministeringGeachGdose.GCheckingGtheGclient’sGperipheralGpulses,GtheGresultsGofGth
eGmostGrecentGpotassiumGlevel,GandGtheGintakeGandGoutputGforGtheG previousG24Ghou
rsGareGnotGspecificallyGassociatedGwithGthisGmediation.
Test-
TakingGStrategy:GFocusGonGtheGnameGofGtheGmedicationGandGrecallGthatGmedica
tionsGthatGendGinGtheGlettersG“pril”GareGACEGinhibitorsGandGthatGtheseGmedicati
onsGareGusedGtoGtreatGhypertension.GThisGwillGdirectGyouGtoGtheGcorrectGoption.G
ReviewGtheGactionGofGenalaprilGmaleateGifGyouGhadGdifficultyGwithGthisGquestion
.
Reference:GLehne,GR.G(2013).GPharmacologyGforGnursingGcareG(8thGG ed.,Gp.G513).GSt.G
Louis:GSaunders.
CognitiveGAbility:GAnalyzing
ClientGNeeds:GPhysiologicalGIntegrity
IntegratedGProcess:GNursingGProcess/Assessment
ContentG Area:G Pharmacology
GiddensG Concepts:G CareG Coordination,G Safety
HESIGConcepts:Collaboration/ManagingGCare,GSafety
AwardedG0.0GpointsGoutGofG1.0GpossibleGpoints.
2.ID:G9476754035
AGclientGisGscheduledGtoGundergoGanG upperGgastrointestinalG(GI)Gseries,GandGth
eGnurseGprovidesGinstructionsGtoGtheGclientGaboutGtheGtest.GWhichGstatementGb
yGtheGclientGindicatesGaGneedG forG furtherG instruction?
A. G GG"TheGtestGwillGtakeGaboutG30Gminutes."
B. G GG"IGneedGtoGfastGforG8GhoursGbeforeGtheGtest."GIncorrect
C. G
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
"IGneedGtoG drinkGcitrateGofGmagnesiaGtheGnightGbeforeGtheGtestGan
GGGG
dGgiveGmyselfGaGFleetGenemaGonGtheGmorningGofGtheGtest."G Correct
D. G G
G G "IGneedGtoGtakeGaGlaxativeGafterGthe GtestGisGcompleted,GbecauseGtheG liqu
Rationale: idGGAn G upperG GIG seriesG involvesG visualizationG ofG theG esophagus,G duodenum,
that GI’llGhaveGtoGdrinkGforGtheGtest GcanGbeGconstipating."
GandGupperGjejunumG byGmeansGofGtheGuseGofGa GcontrastGmedium.GItGinvolvesGswallo
wingGaGcontrastGmediumG(usuallyGbarium),GwhichGisGadministeredGinGaGflavoredG mil
kshake.G FilmsG areG takenG atG intervalsG duringG theG test,G whichG takesGaboutG 30G minute
s.G NoG specialG preparationG isG necessaryG beforeGaG GIG series,GexceptGthatGNPOGstatusG
mustGbeGmaintainedGforG8GhoursGbeforeGtheGtest.GAfterGanGupperGGI
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
series,GtheGclientGisGprescribedGaGlaxativeGtoGhastenGeliminationGofGtheGbarium.GBar
iumGthatGremainsGinGtheGcolonGmayGbecomeGhardGandGdifficultGtoGexpel,GleadingGtoG
fecalGimpaction.
Test-
TakingGStrategy:GUseGtheGprocessGofGelimination.GNoteGtheGstrategicGwordsG"needGfo
rG furtherG instruction."GTheseGwordsG indicateGaGnegativeG eventGqueryG andGtheGneedG
toGselectGtheGincorrectGclientGstatement.GFocusingGonGtheGwordG"upper"GinGtheGname
GofGtheGtestGwillGdirectGyouGtoGtheGcorrectGoption.GReviewGpreprocedureGcareGforGan
GupperGGIGseriesGifGyouGhadGdifficultyGwithGthisGquestion.
Reference:GLewis,GS.,GDirksen,GS.,GHeitkemper,GM.,G&GBucher,GL.G(2014).GMedical-
surgicalGnursing:GAssessmentGandGmanagementGofGclinicalGproblemsG (9thGG ed.,Gp.G87
G
9).GSt.GLouis:GMosby.
CognitiveGAbility:GEvaluating
ClientGNeeds:GPhysiologicalGIntegrityGIntegrate
dG Process:G TeachingGandGLearningGContentGAre
a:GAdultGHealth/Gastrointestinal
GiddensGConcepts:GClientGEducation,GClinicalGJudgment
HESIGConcepts:ClinicalGDecisionGMaking/ClinicalGJudgment,GTeachingGandGLearning/
Patient
Awarded GEducation
G 0.0GpointsGoutG ofG1.0 GpossibleGpoints.
3.ID:G9476790957
AG nurseG onG theG eveningG shiftG checksG aG healthG careG provider'sG prescriptionsG an
dGnotesGthatGtheG doseG ofG aGprescribedG medicationG isGhigherGthanGtheGnormalGd
ose.GTheG nurseG callsG theG healthG careG provider'sG answeringG serviceG andG isG toldG
thatG theGhealthGcareGproviderGisGoffGforGtheGnightGandGwillGbeGavailableGinGtheG
morning.GTheGnurseGshould:
A. G CallG theG nursingG supervisor
GG
B. G AskGtheGansweringG serviceGtoGcontactGtheGon-
GG
callGhealthGcareGproviderGCorrect
C. G
WithholdGtheGmedicationGuntilGtheGhealthGcareGproviderGcanGbeGre
GGGG
achedGinGtheGmorning
D. G G
G G AdministerGtheGmedicationGbutGconsultGtheGhealthGcareGprovider G whe
Rationale: GTheGnurseGhasGaGdutyGtoGprotectGtheGclientGfromGharm.GAGnurseGwhoGbeli
nGheGbecomesGavailable
evesGthatGaGhealthGcareGprovider’sGprescriptionGmayGbeGinGerrorGisGresponsibleGforGc
larifyingGtheGprescriptionGbeforeGcarryingGitGout.GThereforeGtheGnurseGwouldGnotGad
ministerGtheGmedication;Ginstead,GtheGnurseGwouldGwithholdGtheGmedicationGuntilGt
heGdoseGcanGbeGclarified.GTheGnurseGwouldGnotGwaitGuntilGtheGnextGmorningGtoGobtai
nGclarification.GItGisGprematureGtoGcallGtheGnursingGsupervisor.
Test-
TakingGStrategy:GUseGtheGprocessGofGeliminationGandGyourGknowledgeGofGtheGlegalGr
esponsibilitiesGofGtheGnurseGinGregardGtoGmedicationGadministrationGandGhealthGcar
eGprovider’sGprescriptions.GEliminateGtheGoptionsGthatGareGcomparableGorGalikeGinGth
atGtheyGavoidGclarificationGofGtheGprescriptionG(administeringGtheGmedicationGandGh
oldingGtheGmedication).GToGselectGfromGtheGremainingGoptions,GnoteGthatGitGisGprem
atureGtoGcallGtheGnursingGsupervisor.GAlsoGnoteGthatGtheGcorrectGoptionGisGtheGonlyGo
neGthatGclarifiesGtheGprescription.GReviewGlegalGresponsibilitiesGinGregardGtoGmedica
tionGprescriptionsGifGyouGhadGdifficultyGwithGthisGquestion.
Reference:GPotter,GP.,GPerry,GA.GG.,GStockert,GP.GA.,G&GHall,GA.GM.G(2013
).GFundamentalsGofGnursing.G(8thGG ed.,Gp.585).GSt.GLouis:GMosby.GCogniti
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
ClientGNeeds:GSafeGandGEffectiveGCareGEnvironmentGInteg
ratedGProcess:GNursingGProcess/ImplementationGContentG
Area:GLeadershipGandGManagement
GiddensGConcepts:GClinicalGJudgment,GLeadership
HESIGConcepts:Collaboration/ManagingGCare,GClinicalGDecisionGMaking/ClinicalGJud
gment
AwardedG1.0GpointsGoutGofG1.0GpossibleGpoints.
4.ID:G9476788615
AnG emergencyG departmentG (ED)G nurseG isG monitoringG aG clientG withG suspectedG ac
uteGmyocardialGinfarctionG(MI)GwhoGisGawaitingGtransferGtoGtheGcoronaryGintensiv
eGcareGunit.GTheGnurseGnotesGtheGsuddenGonsetGofGprematureGventricularGcontra
ctionsG(PVCs)GonGtheG monitor,GchecksGtheGclient'sGcarotidGpulse,GandGdetermine
sGthatGtheGPVCsGareGnotGresultingGinGperfusion.GTheGappropriateGactionGbyGtheGn
urseGis:
A. G GGDocumentingG theG findings
B. G GGAskingG theG EDG healthG careG providerG toG checkG theG clientG Correct
C. G GGGG ContinuingG toG monitorG theG client'sG cardiacG status
D. GInformingGtheGclientGthatGPVCsGareGexpectedGafterGanGMI
GG
Rationale:GPVCsGareGaGresultGofGincreasedGirritabilityGofGventricularGcells.GPeripheral
GpulsesG mayG beG absentG orG diminishedG withG theG PVCsG themselvesG becauseG theGdecre
asedG strokeG volumeG ofGtheG prematureG beatsG mayG inG turnG decreaseG peripheralGperfu
sion.GBecauseG otherG rhythmsGalsoGcauseGwidenedGQRSGcomplexes,GitG isGessentialGth
atGtheGnurseGdetermineGwhetherGtheGprematureGbeatsGareGresultingGinGperfusionGof
GtheGextremities.GThisGisGdoneGbyGpalpatingGtheGcarotid,Gbrachial,GorGfemoralGartery
GwhileGobservingGtheGmonitorGforGwidenedGcomplexesGorGbyGauscultatingG forGapicalG
heartGsounds.GInGtheGsituationGofGacuteGMI,GPVCsGmayGbeGconsideredGwarningG dysrh
ythmias,G possiblyG heraldingG theG onsetG ofGventricularGtachycardiaGorGventricularGfibr
illation.GThereforeGtheGnurseGwouldGnotGtellGtheGclientGthatGtheG PVCsGareGexpected.G
AlthoughG theG nurseG willGcontinueG toGmonitorG theGclientGandGdocumentGtheGfindings
,GtheseGareGnotGtheGmostGappropriateGactionsGofGthoseGprovided.GTheG mostGappropr
iateG actionGwouldGbeGtoGaskGtheG EDGhealthGcareGproviderGtoGcheckGtheGclient.
Test-
TakingGStrategy:GUseGtheGprocessGofGelimination.GRecallingGtheGsignificanceGofGPVCsG
afterG acuteG MIGandG notingG theG strategicG wordsG "notG perfusing"G willG directGyouGtoGth
eGcorrectGoption.GReviewGtheGsignificanceGofGPVCsGafterGacuteGMIGifGyouGhadGdifficu
ltyGwithGthisGquestion.
Reference:GLewis,GS.,GDirksen,GS.,GHeitkemper,GM.,G&GBucher,GL.G(2014).GMedical-
surgicalGnursing:GAssessmentGandGmanagementGofGclinicalGproblemsG (9thGG ed.,Gp.G79
G
9).GSt.GLouis:GMosby.
CognitiveGAbility:GApplying
ClientGNeeds:GPhysiologicalGIntegrity
IntegratedGProcess:GNursingGProcess/Implementation
ContentGArea:GCriticalGCare
GiddensGConcepts:GClinicalGJudgment,GPerfusion
HESIGConcepts:GClinicalGDecisionGMaking/ClinicalGJudgment,GPerfusion
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
1.ID:G9476788675
EnalaprilG maleateG isG prescribedG forG aG hospitalizedG client.G WhichG assessmentG d
oesGtheGnurseGperformGasGaGpriorityG beforeGadministeringG theGmedication?
A. CheckingGtheGclient'sGbloodGpressur Correct
e
B. CheckingG theG client'sG peripheralG pulses
C. G GGGG CheckingGtheGmostGrecentGpotassiumGlevel
D. CheckingGtheGclient'sGintake-and-
G GG
outputGrecordGforGtheG lastG24GhoursGIncorrect
Rationale:G EnalaprilG maleateG isG anG angiotensin-
convertingG enzymeG (ACE)G inhibitorGusedGtoGtreatGhypertension.GOneGcommonGsideGe
ffectGisGposturalGhypotension.
ThereforeGtheGnurseGwouldGcheckGtheGclient’sGbloodGpressureGimmediatelyGbeforeGa
dministeringGeachGdose.GCheckingGtheGclient’sGperipheralGpulses,GtheGresultsGofGth
eGmostGrecentGpotassiumGlevel,GandGtheGintakeGandGoutputGforGtheG previousG24Ghou
rsGareGnotGspecificallyGassociatedGwithGthisGmediation.
Test-
TakingGStrategy:GFocusGonGtheGnameGofGtheGmedicationGandGrecallGthatGmedica
tionsGthatGendGinGtheGlettersG“pril”GareGACEGinhibitorsGandGthatGtheseGmedicati
onsGareGusedGtoGtreatGhypertension.GThisGwillGdirectGyouGtoGtheGcorrectGoption.G
ReviewGtheGactionGofGenalaprilGmaleateGifGyouGhadGdifficultyGwithGthisGquestion
.
Reference:GLehne,GR.G(2013).GPharmacologyGforGnursingGcareG(8thGG ed.,Gp.G513).GSt.G
Louis:GSaunders.
CognitiveGAbility:GAnalyzing
ClientGNeeds:GPhysiologicalGIntegrity
IntegratedGProcess:GNursingGProcess/Assessment
ContentG Area:G Pharmacology
GiddensG Concepts:G CareG Coordination,G Safety
HESIGConcepts:Collaboration/ManagingGCare,GSafety
AwardedG0.0GpointsGoutGofG1.0GpossibleGpoints.
2.ID:G9476754035
AGclientGisGscheduledGtoGundergoGanG upperGgastrointestinalG(GI)Gseries,GandGth
eGnurseGprovidesGinstructionsGtoGtheGclientGaboutGtheGtest.GWhichGstatementGb
yGtheGclientGindicatesGaGneedG forG furtherG instruction?
A. G GG"TheGtestGwillGtakeGaboutG30Gminutes."
B. G GG"IGneedGtoGfastGforG8GhoursGbeforeGtheGtest."GIncorrect
C. G
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
"IGneedGtoG drinkGcitrateGofGmagnesiaGtheGnightGbeforeGtheGtestGan
GGGG
dGgiveGmyselfGaGFleetGenemaGonGtheGmorningGofGtheGtest."G Correct
D. G G
G G "IGneedGtoGtakeGaGlaxativeGafterGthe GtestGisGcompleted,GbecauseGtheG liqu
Rationale: idGGAn G upperG GIG seriesG involvesG visualizationG ofG theG esophagus,G duodenum,
that GI’llGhaveGtoGdrinkGforGtheGtest GcanGbeGconstipating."
GandGupperGjejunumG byGmeansGofGtheGuseGofGa GcontrastGmedium.GItGinvolvesGswallo
wingGaGcontrastGmediumG(usuallyGbarium),GwhichGisGadministeredGinGaGflavoredG mil
kshake.G FilmsG areG takenG atG intervalsG duringG theG test,G whichG takesGaboutG 30G minute
s.G NoG specialG preparationG isG necessaryG beforeGaG GIG series,GexceptGthatGNPOGstatusG
mustGbeGmaintainedGforG8GhoursGbeforeGtheGtest.GAfterGanGupperGGI
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
series,GtheGclientGisGprescribedGaGlaxativeGtoGhastenGeliminationGofGtheGbarium.GBar
iumGthatGremainsGinGtheGcolonGmayGbecomeGhardGandGdifficultGtoGexpel,GleadingGtoG
fecalGimpaction.
Test-
TakingGStrategy:GUseGtheGprocessGofGelimination.GNoteGtheGstrategicGwordsG"needGfo
rG furtherG instruction."GTheseGwordsG indicateGaGnegativeG eventGqueryG andGtheGneedG
toGselectGtheGincorrectGclientGstatement.GFocusingGonGtheGwordG"upper"GinGtheGname
GofGtheGtestGwillGdirectGyouGtoGtheGcorrectGoption.GReviewGpreprocedureGcareGforGan
GupperGGIGseriesGifGyouGhadGdifficultyGwithGthisGquestion.
Reference:GLewis,GS.,GDirksen,GS.,GHeitkemper,GM.,G&GBucher,GL.G(2014).GMedical-
surgicalGnursing:GAssessmentGandGmanagementGofGclinicalGproblemsG (9thGG ed.,Gp.G87
G
9).GSt.GLouis:GMosby.
CognitiveGAbility:GEvaluating
ClientGNeeds:GPhysiologicalGIntegrityGIntegrate
dG Process:G TeachingGandGLearningGContentGAre
a:GAdultGHealth/Gastrointestinal
GiddensGConcepts:GClientGEducation,GClinicalGJudgment
HESIGConcepts:ClinicalGDecisionGMaking/ClinicalGJudgment,GTeachingGandGLearning/
Patient
Awarded GEducation
G 0.0GpointsGoutG ofG1.0 GpossibleGpoints.
3.ID:G9476790957
AG nurseG onG theG eveningG shiftG checksG aG healthG careG provider'sG prescriptionsG an
dGnotesGthatGtheG doseG ofG aGprescribedG medicationG isGhigherGthanGtheGnormalGd
ose.GTheG nurseG callsG theG healthG careG provider'sG answeringG serviceG andG isG toldG
thatG theGhealthGcareGproviderGisGoffGforGtheGnightGandGwillGbeGavailableGinGtheG
morning.GTheGnurseGshould:
A. G CallG theG nursingG supervisor
GG
B. G AskGtheGansweringG serviceGtoGcontactGtheGon-
GG
callGhealthGcareGproviderGCorrect
C. G
WithholdGtheGmedicationGuntilGtheGhealthGcareGproviderGcanGbeGre
GGGG
achedGinGtheGmorning
D. G G
G G AdministerGtheGmedicationGbutGconsultGtheGhealthGcareGprovider G whe
Rationale: GTheGnurseGhasGaGdutyGtoGprotectGtheGclientGfromGharm.GAGnurseGwhoGbeli
nGheGbecomesGavailable
evesGthatGaGhealthGcareGprovider’sGprescriptionGmayGbeGinGerrorGisGresponsibleGforGc
larifyingGtheGprescriptionGbeforeGcarryingGitGout.GThereforeGtheGnurseGwouldGnotGad
ministerGtheGmedication;Ginstead,GtheGnurseGwouldGwithholdGtheGmedicationGuntilGt
heGdoseGcanGbeGclarified.GTheGnurseGwouldGnotGwaitGuntilGtheGnextGmorningGtoGobtai
nGclarification.GItGisGprematureGtoGcallGtheGnursingGsupervisor.
Test-
TakingGStrategy:GUseGtheGprocessGofGeliminationGandGyourGknowledgeGofGtheGlegalGr
esponsibilitiesGofGtheGnurseGinGregardGtoGmedicationGadministrationGandGhealthGcar
eGprovider’sGprescriptions.GEliminateGtheGoptionsGthatGareGcomparableGorGalikeGinGth
atGtheyGavoidGclarificationGofGtheGprescriptionG(administeringGtheGmedicationGandGh
oldingGtheGmedication).GToGselectGfromGtheGremainingGoptions,GnoteGthatGitGisGprem
atureGtoGcallGtheGnursingGsupervisor.GAlsoGnoteGthatGtheGcorrectGoptionGisGtheGonlyGo
neGthatGclarifiesGtheGprescription.GReviewGlegalGresponsibilitiesGinGregardGtoGmedica
tionGprescriptionsGifGyouGhadGdifficultyGwithGthisGquestion.
Reference:GPotter,GP.,GPerry,GA.GG.,GStockert,GP.GA.,G&GHall,GA.GM.G(2013
).GFundamentalsGofGnursing.G(8thGG ed.,Gp.585).GSt.GLouis:GMosby.GCogniti
, NURS 3345-
GGG G
265 MORSELS OF EXIT HESI QUESTIONS AND ANSWERS 2023/
G G G G G G G G
2024 BEST EXAM SOLUTION TOP RANKED A+ FOR SUCCESS
G G G G G G G G
ClientGNeeds:GSafeGandGEffectiveGCareGEnvironmentGInteg
ratedGProcess:GNursingGProcess/ImplementationGContentG
Area:GLeadershipGandGManagement
GiddensGConcepts:GClinicalGJudgment,GLeadership
HESIGConcepts:Collaboration/ManagingGCare,GClinicalGDecisionGMaking/ClinicalGJud
gment
AwardedG1.0GpointsGoutGofG1.0GpossibleGpoints.
4.ID:G9476788615
AnG emergencyG departmentG (ED)G nurseG isG monitoringG aG clientG withG suspectedG ac
uteGmyocardialGinfarctionG(MI)GwhoGisGawaitingGtransferGtoGtheGcoronaryGintensiv
eGcareGunit.GTheGnurseGnotesGtheGsuddenGonsetGofGprematureGventricularGcontra
ctionsG(PVCs)GonGtheG monitor,GchecksGtheGclient'sGcarotidGpulse,GandGdetermine
sGthatGtheGPVCsGareGnotGresultingGinGperfusion.GTheGappropriateGactionGbyGtheGn
urseGis:
A. G GGDocumentingG theG findings
B. G GGAskingG theG EDG healthG careG providerG toG checkG theG clientG Correct
C. G GGGG ContinuingG toG monitorG theG client'sG cardiacG status
D. GInformingGtheGclientGthatGPVCsGareGexpectedGafterGanGMI
GG
Rationale:GPVCsGareGaGresultGofGincreasedGirritabilityGofGventricularGcells.GPeripheral
GpulsesG mayG beG absentG orG diminishedG withG theG PVCsG themselvesG becauseG theGdecre
asedG strokeG volumeG ofGtheG prematureG beatsG mayG inG turnG decreaseG peripheralGperfu
sion.GBecauseG otherG rhythmsGalsoGcauseGwidenedGQRSGcomplexes,GitG isGessentialGth
atGtheGnurseGdetermineGwhetherGtheGprematureGbeatsGareGresultingGinGperfusionGof
GtheGextremities.GThisGisGdoneGbyGpalpatingGtheGcarotid,Gbrachial,GorGfemoralGartery
GwhileGobservingGtheGmonitorGforGwidenedGcomplexesGorGbyGauscultatingG forGapicalG
heartGsounds.GInGtheGsituationGofGacuteGMI,GPVCsGmayGbeGconsideredGwarningG dysrh
ythmias,G possiblyG heraldingG theG onsetG ofGventricularGtachycardiaGorGventricularGfibr
illation.GThereforeGtheGnurseGwouldGnotGtellGtheGclientGthatGtheG PVCsGareGexpected.G
AlthoughG theG nurseG willGcontinueG toGmonitorG theGclientGandGdocumentGtheGfindings
,GtheseGareGnotGtheGmostGappropriateGactionsGofGthoseGprovided.GTheG mostGappropr
iateG actionGwouldGbeGtoGaskGtheG EDGhealthGcareGproviderGtoGcheckGtheGclient.
Test-
TakingGStrategy:GUseGtheGprocessGofGelimination.GRecallingGtheGsignificanceGofGPVCsG
afterG acuteG MIGandG notingG theG strategicG wordsG "notG perfusing"G willG directGyouGtoGth
eGcorrectGoption.GReviewGtheGsignificanceGofGPVCsGafterGacuteGMIGifGyouGhadGdifficu
ltyGwithGthisGquestion.
Reference:GLewis,GS.,GDirksen,GS.,GHeitkemper,GM.,G&GBucher,GL.G(2014).GMedical-
surgicalGnursing:GAssessmentGandGmanagementGofGclinicalGproblemsG (9thGG ed.,Gp.G79
G
9).GSt.GLouis:GMosby.
CognitiveGAbility:GApplying
ClientGNeeds:GPhysiologicalGIntegrity
IntegratedGProcess:GNursingGProcess/Implementation
ContentGArea:GCriticalGCare
GiddensGConcepts:GClinicalGJudgment,GPerfusion
HESIGConcepts:GClinicalGDecisionGMaking/ClinicalGJudgment,GPerfusion
