HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
AndERdnursedisdcompletingdandassessmentdondadpatientdthatdisdalertdbutdstrugglesdtodansw
erdquestions.dWhendshedattemptsdtodtalk,dshedslursdherdspeechdanddappearsdverydfrightene
d.dWhatdadditionaldclinicaldmanifestationddoesdthednursedexpectdtodfinddifdnacy'sdsysmptom
sdhavedbeendcauseddbydadbraindattackd(stroke)?
A.dAdcarotiddbruit
B.dAdhypotensivedblooddpressure
C.dhyperreflexicddeepdtendondrelexes.
D.dDecreaseddboweldsoundsd-dA)dAdcarotiddbruit.
Rationale:dthedcarotiddarteryd(arterydtodthedbrain)disdnarroweddindclientsdwithdadbraindattack.d
Adbruitdisdandabnormaldsounddhearddondauscultationdresultingdfromdinterferencedwithdnorm
aldblooddflow.dUsuallydthedblooddpressuredisdhypertensive.dInitiallydflacciddparalysisdoccurs,
dresultingdindhyporefkexicddeepdtendondreflexes.dBoweldsoundsdarednotdindicativedofdadbrai
ndattack.
Whichdclinicaldmanifestationdfurtherdsupportsdandassessmentdofdadleft-sideddbraindattack?
A)dVisualdfieldddeficitdondthedleftdside.
B)dSpatial-perceptualddeficits.
C)dParesthesiadofdthedleftdside.
D)dGlobaldaphasia.
D)dGlobaldaphasia.d-dD)dGlobaldaphasia.
Rationale:dGlobaldaphasiadrefersdtoddifficultydspeaking,dlistening,danddunderstanding,dasdw
elldasddifficultydreadingdanddwriting.dSymptomsdvarydfromdpersondtodperson.dAphasiadmaydo
ccurdsecondarydtodanydbraindinjurydinvolvingdthedleftdhemisphere.dVisualdfieldddeficits,dspati
al-perceptualddeficits,danddparesthsiadofdthedleftdsidedusuallydoccurdwithdright-
sideddbraindattack.
Whendpreparingdadpatientdfordadnoncontrastdcomputeddtomographyd(CT)dscandSTAT,dwhat
dnursingdinterventiondshoulddthednursedimplement?
A)dDeterminedifdthedclientdhasdanydallergiesdtodiodine
B)dExplaindthatdthedclientdwilldnotdbedabledtodmovedherdheaddthroughoutdthedCTdscan.
C)dPremedicatedthedclientdtoddecreasedpaindpriordtodhavingdthedprocedure.
,D)dProvidedandexplanationdofdrelaxationdexercisesdpriordtodthedprocedure.d-
dB)dExplaindthatdthedclientdwilldnotdbedabledtodmovedherdheaddthroughoutdthedCTdscan.
Rationale:dBecausedheaddmotiondwillddistortdthedimages,dNancydwilldhavedtodremaindstilldthr
oughoutdthedprocedure.dAllergiesdtodiodinedisdimportantdifdcontrastddyedisdbeingduseddfordth
edCTdscan.dPremedicatingdthedclientdtoddecreasedpaindpriordtodthedproceduredisdunnecessa
rydbecausedCTdscanningdisdadnoninvasivedanddpainlessdprocedure.dProvidingdandexplanati
ondofdrelaxationdexercisesdpriordtodthedproceduredisdadworthwhiledinterventiondtoddecreased
anxietydbutdisdnotdofdhighestdpriority.
Adneurologistdprescribesdadmagneticdresonancedimagingd(MRI)dofdthedheaddSTATdfordadpat
ient.dWhichddatadwarrantsdimmediatedinterventiondbydthednursedconcerningdthisddiagnosticd
test?
A)dElevateddblooddpressure.
B)dAllergydtodshelldfish.
C)dRightdhipdreplacement.
D)dHistorydofdatrialdfibrillation.d-dC)dRightdhipdreplacement.
ThedmagneticdfielddgenerateddbydthedMRIdisdsodstrongdthatdmetal-
containingditemsdaredstronglydattracteddtodthedmagnet.dBecausedthedhipdjointdisdmadedofdme
tal,dadleaddshielddmustdbeduseddduringdthedprocedure.dElevateddblooddpressure,dandallergyd
todshelldfish,danddadhistorydofdatrialdfibrillationdwoulddnotdaffectdthedMRI.
Adclient'sddaughterdisdsittingdbydherdmother'sdbedsidedwhodwasdrecentlydtransferreddtodthedI
ntermediatedCaredUnit.dShedstatesd"Iddon'tdunderstanddwhatdadbraindattackdis.dThedhealthc
aredproviderdtolddmedmydmotherdisdindseriousdconditiondanddtheydaredgoingdtodrundseveraldte
sts.dIdjustddon'tdknowdwhatdisdgoingdon.dWhatdhappeneddtodmydmother?"dWhatdisdthedbestdre
sponsedbydthednurse?
A)d"Idamdsorry,dbutdaccordingdtodthedHealthdInsurancedPortabilitydanddAccountingdActd(HIP
AA),dIdcannotdgivedyoudanydinformation."
B)d"Yourdmotherdhasdhaddadstroke,danddthedblooddsupplydtodthedbraindhasdbeendblocked."
C)d"Howddodyoudfeeldaboutdwhatdthedhealthcaredproviderdsaid?"
D)d"Idwilldcalldthedhealthcaredproviderdsodhe/shedcandtalkdtodyoudaboutdyourdmother'sdseriou
sdcondition."d-
dB)d"Yourdmotherdhasdhaddadstroke,danddthedblooddsupplydtodthedbraindhasdbeendblocked."
Rationale:dThednursedcanddiscussdwhatdaddiagnosisdmeans.dNancydisdunabledtodmakeddeci
sions,dsodthednextdofdkin,dherddaughter,dGail,dneedsdsufficientdinformationdtodmakedinforme
dddecisions.dThednursedhasdthedknowledge,danddthedresponsibility,dtodexplaindNancy'sdcon
ditiondtodGail.dThednursedshoulddgivedfactsdfirst,danddthendaddressdherdfeelingsdafterdthedinf
ormationdisdprovided.
,Whatdisdthednormaldrangedfordcardiacdoutput?d-
dThednormaldrangedfordcardiacdoutputdtodensuredcerebraldblooddflowdanddoxygenddeliverydis
d4dtod8dL/min.
Adclientdwasdadmitteddwithdtheddiagnosisdofdadbraindattack.dTheirdsymptomsdbegand24dhour
sdbeforedbeingdadmitted.dWhydwoulddthisdclientdnotdbedadcandidatedfordfordthrombolyticdther
apy?d-
dThrombolyticdtherapydisdcontraindicateddindclientsdwithdsymptomdonsetdlongerdthand3dhour
sdpriordtodadmission.dThisdclientdhaddsymptomsdford24dhoursdbeforedbeingdbroughtdtodthedm
edicaldcenter
Whatdaredplatedguards?d-
dPlatedguardsdpreventdfooddfromdbeingdpusheddoff dthedplate.dUsingdplatedguardsdanddotherd
assistiveddevicesdwilldencouragedindependencedindadclientdwithdadself-careddeficit.
Whichdconditiondisdconsidereddadnon-modifiabledriskdfactordfordadbraindattack?
A)dHighdcholesteroldlevels.
B)dObesity.
C)dHistorydofdatrialdfibrillation.
D)dAdvanceddage.d-dD)dAdvanceddage.
Rationale:dPeopledoverdaged55daredadhigh-
riskdgroupdfordadbraindattackdbecausedthedincidencedofdstrokedmoredthanddoublesdindeachds
uccessiveddecadedofdlife.dNon-
modifiabledmeansdthedclientdcannotddodanythingdtodchangedthedriskdfactor.dAlldthedotherdopti
onsdaredmodifiabledriskdfactors.
Adclientdisdexperiencingdhomonymousdhemianopsiadasdthedresultdofdadbraindattack.dWhichd
nursingdinterventiondwoulddthednursedimplementdtodaddressdthisdcondition?
A)dTurndNancydeverydtwodhoursdanddperformdactivedrangedofdmotiondexercises.
B)dPlacedthedobjectsdNancydneedsdfordactivitiesdofddailydlivingdondthedleftdsidedofdthedtable.
C)dSpeakdslowlydanddclearlydtodassistdNancydindformingdsoundsdtodwords.
D)dRequestdthatdtheddietaryddepartmentdthickendalldliquidsdondNancy'sdmealdanddsnackdtray
s.d-
dB)dPlacedthedobjectsdNancydneedsdfordactivitiesdofddailydlivingdondthedleftdsidedofdthedtable.
Rationale:dHomonymousdhemianopsiadisdlossdofdthedvisualdfielddondthedsamedsidedasdthedp
aralyzeddside.dThisdresultsdindthedclientdneglectingdthatdsidedofdthedbody,dsoditdisdbeneficialdt
odplacedobjectsdondthatdside.dNancydhaddadleft-
hemispheredbraindattackdsodherdrightdsidedisdthedweakdside.dSpeakingdslowlydanddclearlydw
oulddaddressdthedclient'sdverbalddeficitsdduedtodaphasia.dRequestingdalldliquidsdtodbedthicke
neddwoulddaddressddysphagia.dTurningdthedclientdeveryd2dhoursdanddperformingdactivedran
gedofdmotiondexercisesdwoulddaddressdthedclient'sdriskdfordimmobilitydduedtodparalysis.
, Adphysicaldtherapistd(PT)dplacesdadgaitdbeltdondadclientdanddisdassistingdthemdwithdambulati
ondfromdthedbeddtodthedchair.dAsdtheydgetdupdoutdofdthedbed,dtheydreportdbeingddizzydanddbe
gindtodfall.dThedPTdcarefullydallowsdthemdtodfalldbackdtodthedbeddanddnotifiesdthedprimarydnur
se.dWhichdwrittenddocumentationdshoulddthednursedputdindthedclient'sdrecord?d
A)dClientdexperienceddorthostaticdhypotensiondwhendgettingdoutdofdbed.
B)dPTdreporteddclientdcomplaineddofddizzinessdwhendgettingdoutdofdbed,danddgaitdbeltdwasdu
seddtodallowdclientdtodfalldbackdontodthedbed.
C)dPTdnotifieddthedprimarydnursedthatdthedclientdcoulddnotdambulatedatdthisdtimedbecausedofd
dizziness.
D)dClientdhadddifficultydambulatingdfromdthedbeddtodthedchairdwhendaccompanieddbydthedPT
,dvariancedreportdcompleted.d-
dB)dPTdreporteddclientdcomplaineddofddizzinessdwhendgettingdoutdofdbed,danddgaitdbeltdwasd
useddtodallowdclientdtodfalldbackdontodthedbed.
Rationale:dThisddocumentationdprovidesdthedfactualddatadofdthedeventsdthatdoccurred.dA)Th
ednursedisdmakingdandassumptiondthatdtheddizzinessdwasdcauseddbydorthostaticdhypotensio
n.dC)dNotdalldthedpertinentdfactsdaredincludeddindthisddocumentation.
D)dAdvariancedreportdshoulddneverdbeddocumenteddindthedclient'sdrecord.
Adnewdnursedgraduatedisdcaringdfordadpostoperativedclientdwithdthedfollowingdarterialdbloodd
gasesd(ABGs):dpH,d7.30;dPCO2,d60dmmdHg;dPO2,d80dmmdHg;dbicarbonate,d24dmEq/L;dand
dO2dsaturation,d96%.dWhichdofdthesedactionsdbydthednewdgraduatedisdindicated?
A)dEncouragedthedclientdtodusedthedincentivedspirometerdanddtodcough.
B)dAdministerdoxygendbydnasaldcannula.
C)dRequestdadprescriptiondfordsodiumdbicarbonatedfromdthedhealthdcaredprovider.
D)dInformdthedchargednursedthatdnodchangesdindtherapydaredneeded.d-
dA)dEncouragedthedclientdtodusedthedincentivedspirometerdanddtodcough.
Rationale:dRespiratorydacidosisdisdcauseddbydCO2dretentiondanddimpaireddchestdexpansio
ndsecondarydtodanesthesia.dThednursedtakesdstepsdtodpromotedCO2delimination,dincludingd
maintainingdadpatentdairwaydanddexpandingdthedlungsdthroughdbreathingdtechniques.dO2dis
dnotdindicateddbecausedPo2danddoxygendsaturationdaredwithindthednormaldrange.dSodiumdbi
carbonatedisdnotdindicateddbecausedthedbicarbonatedleveldisdindthednormaldrange;dpromotin
gdexcretiondofdrespiratorydacidsdisdthedprioritydindrespiratorydacidosis.dPostdanesthesia,dthed
clientdwilldneeddinterventionsdasddescribeddindAdabovedordmaydprogressdtodadstatedofdsomno
lencedanddunresponsiveness.
Thednursedisdprovidingddietarydinstructionsdtodad68-year-
olddclientdwhodisdatdhighdriskdforddevelopmentdofdcoronarydheartddiseased(CHD).dWhichdinfo
rmationdshoulddthednursedinclude?
A)dLimitddietarydselectiondofdcholesteroldtod300dmgdperdday
B)dIncreasedintakedofdsolubledfiberdtod10dtod25dgramsdperdday.d
C)dDecreasedplantdstanolsdanddsterolsdtodlessdthand2dgrams/day.d
PACK 2024 QUESTIONS AND ANSWERS
AndERdnursedisdcompletingdandassessmentdondadpatientdthatdisdalertdbutdstrugglesdtodansw
erdquestions.dWhendshedattemptsdtodtalk,dshedslursdherdspeechdanddappearsdverydfrightene
d.dWhatdadditionaldclinicaldmanifestationddoesdthednursedexpectdtodfinddifdnacy'sdsysmptom
sdhavedbeendcauseddbydadbraindattackd(stroke)?
A.dAdcarotiddbruit
B.dAdhypotensivedblooddpressure
C.dhyperreflexicddeepdtendondrelexes.
D.dDecreaseddboweldsoundsd-dA)dAdcarotiddbruit.
Rationale:dthedcarotiddarteryd(arterydtodthedbrain)disdnarroweddindclientsdwithdadbraindattack.d
Adbruitdisdandabnormaldsounddhearddondauscultationdresultingdfromdinterferencedwithdnorm
aldblooddflow.dUsuallydthedblooddpressuredisdhypertensive.dInitiallydflacciddparalysisdoccurs,
dresultingdindhyporefkexicddeepdtendondreflexes.dBoweldsoundsdarednotdindicativedofdadbrai
ndattack.
Whichdclinicaldmanifestationdfurtherdsupportsdandassessmentdofdadleft-sideddbraindattack?
A)dVisualdfieldddeficitdondthedleftdside.
B)dSpatial-perceptualddeficits.
C)dParesthesiadofdthedleftdside.
D)dGlobaldaphasia.
D)dGlobaldaphasia.d-dD)dGlobaldaphasia.
Rationale:dGlobaldaphasiadrefersdtoddifficultydspeaking,dlistening,danddunderstanding,dasdw
elldasddifficultydreadingdanddwriting.dSymptomsdvarydfromdpersondtodperson.dAphasiadmaydo
ccurdsecondarydtodanydbraindinjurydinvolvingdthedleftdhemisphere.dVisualdfieldddeficits,dspati
al-perceptualddeficits,danddparesthsiadofdthedleftdsidedusuallydoccurdwithdright-
sideddbraindattack.
Whendpreparingdadpatientdfordadnoncontrastdcomputeddtomographyd(CT)dscandSTAT,dwhat
dnursingdinterventiondshoulddthednursedimplement?
A)dDeterminedifdthedclientdhasdanydallergiesdtodiodine
B)dExplaindthatdthedclientdwilldnotdbedabledtodmovedherdheaddthroughoutdthedCTdscan.
C)dPremedicatedthedclientdtoddecreasedpaindpriordtodhavingdthedprocedure.
,D)dProvidedandexplanationdofdrelaxationdexercisesdpriordtodthedprocedure.d-
dB)dExplaindthatdthedclientdwilldnotdbedabledtodmovedherdheaddthroughoutdthedCTdscan.
Rationale:dBecausedheaddmotiondwillddistortdthedimages,dNancydwilldhavedtodremaindstilldthr
oughoutdthedprocedure.dAllergiesdtodiodinedisdimportantdifdcontrastddyedisdbeingduseddfordth
edCTdscan.dPremedicatingdthedclientdtoddecreasedpaindpriordtodthedproceduredisdunnecessa
rydbecausedCTdscanningdisdadnoninvasivedanddpainlessdprocedure.dProvidingdandexplanati
ondofdrelaxationdexercisesdpriordtodthedproceduredisdadworthwhiledinterventiondtoddecreased
anxietydbutdisdnotdofdhighestdpriority.
Adneurologistdprescribesdadmagneticdresonancedimagingd(MRI)dofdthedheaddSTATdfordadpat
ient.dWhichddatadwarrantsdimmediatedinterventiondbydthednursedconcerningdthisddiagnosticd
test?
A)dElevateddblooddpressure.
B)dAllergydtodshelldfish.
C)dRightdhipdreplacement.
D)dHistorydofdatrialdfibrillation.d-dC)dRightdhipdreplacement.
ThedmagneticdfielddgenerateddbydthedMRIdisdsodstrongdthatdmetal-
containingditemsdaredstronglydattracteddtodthedmagnet.dBecausedthedhipdjointdisdmadedofdme
tal,dadleaddshielddmustdbeduseddduringdthedprocedure.dElevateddblooddpressure,dandallergyd
todshelldfish,danddadhistorydofdatrialdfibrillationdwoulddnotdaffectdthedMRI.
Adclient'sddaughterdisdsittingdbydherdmother'sdbedsidedwhodwasdrecentlydtransferreddtodthedI
ntermediatedCaredUnit.dShedstatesd"Iddon'tdunderstanddwhatdadbraindattackdis.dThedhealthc
aredproviderdtolddmedmydmotherdisdindseriousdconditiondanddtheydaredgoingdtodrundseveraldte
sts.dIdjustddon'tdknowdwhatdisdgoingdon.dWhatdhappeneddtodmydmother?"dWhatdisdthedbestdre
sponsedbydthednurse?
A)d"Idamdsorry,dbutdaccordingdtodthedHealthdInsurancedPortabilitydanddAccountingdActd(HIP
AA),dIdcannotdgivedyoudanydinformation."
B)d"Yourdmotherdhasdhaddadstroke,danddthedblooddsupplydtodthedbraindhasdbeendblocked."
C)d"Howddodyoudfeeldaboutdwhatdthedhealthcaredproviderdsaid?"
D)d"Idwilldcalldthedhealthcaredproviderdsodhe/shedcandtalkdtodyoudaboutdyourdmother'sdseriou
sdcondition."d-
dB)d"Yourdmotherdhasdhaddadstroke,danddthedblooddsupplydtodthedbraindhasdbeendblocked."
Rationale:dThednursedcanddiscussdwhatdaddiagnosisdmeans.dNancydisdunabledtodmakeddeci
sions,dsodthednextdofdkin,dherddaughter,dGail,dneedsdsufficientdinformationdtodmakedinforme
dddecisions.dThednursedhasdthedknowledge,danddthedresponsibility,dtodexplaindNancy'sdcon
ditiondtodGail.dThednursedshoulddgivedfactsdfirst,danddthendaddressdherdfeelingsdafterdthedinf
ormationdisdprovided.
,Whatdisdthednormaldrangedfordcardiacdoutput?d-
dThednormaldrangedfordcardiacdoutputdtodensuredcerebraldblooddflowdanddoxygenddeliverydis
d4dtod8dL/min.
Adclientdwasdadmitteddwithdtheddiagnosisdofdadbraindattack.dTheirdsymptomsdbegand24dhour
sdbeforedbeingdadmitted.dWhydwoulddthisdclientdnotdbedadcandidatedfordfordthrombolyticdther
apy?d-
dThrombolyticdtherapydisdcontraindicateddindclientsdwithdsymptomdonsetdlongerdthand3dhour
sdpriordtodadmission.dThisdclientdhaddsymptomsdford24dhoursdbeforedbeingdbroughtdtodthedm
edicaldcenter
Whatdaredplatedguards?d-
dPlatedguardsdpreventdfooddfromdbeingdpusheddoff dthedplate.dUsingdplatedguardsdanddotherd
assistiveddevicesdwilldencouragedindependencedindadclientdwithdadself-careddeficit.
Whichdconditiondisdconsidereddadnon-modifiabledriskdfactordfordadbraindattack?
A)dHighdcholesteroldlevels.
B)dObesity.
C)dHistorydofdatrialdfibrillation.
D)dAdvanceddage.d-dD)dAdvanceddage.
Rationale:dPeopledoverdaged55daredadhigh-
riskdgroupdfordadbraindattackdbecausedthedincidencedofdstrokedmoredthanddoublesdindeachds
uccessiveddecadedofdlife.dNon-
modifiabledmeansdthedclientdcannotddodanythingdtodchangedthedriskdfactor.dAlldthedotherdopti
onsdaredmodifiabledriskdfactors.
Adclientdisdexperiencingdhomonymousdhemianopsiadasdthedresultdofdadbraindattack.dWhichd
nursingdinterventiondwoulddthednursedimplementdtodaddressdthisdcondition?
A)dTurndNancydeverydtwodhoursdanddperformdactivedrangedofdmotiondexercises.
B)dPlacedthedobjectsdNancydneedsdfordactivitiesdofddailydlivingdondthedleftdsidedofdthedtable.
C)dSpeakdslowlydanddclearlydtodassistdNancydindformingdsoundsdtodwords.
D)dRequestdthatdtheddietaryddepartmentdthickendalldliquidsdondNancy'sdmealdanddsnackdtray
s.d-
dB)dPlacedthedobjectsdNancydneedsdfordactivitiesdofddailydlivingdondthedleftdsidedofdthedtable.
Rationale:dHomonymousdhemianopsiadisdlossdofdthedvisualdfielddondthedsamedsidedasdthedp
aralyzeddside.dThisdresultsdindthedclientdneglectingdthatdsidedofdthedbody,dsoditdisdbeneficialdt
odplacedobjectsdondthatdside.dNancydhaddadleft-
hemispheredbraindattackdsodherdrightdsidedisdthedweakdside.dSpeakingdslowlydanddclearlydw
oulddaddressdthedclient'sdverbalddeficitsdduedtodaphasia.dRequestingdalldliquidsdtodbedthicke
neddwoulddaddressddysphagia.dTurningdthedclientdeveryd2dhoursdanddperformingdactivedran
gedofdmotiondexercisesdwoulddaddressdthedclient'sdriskdfordimmobilitydduedtodparalysis.
, Adphysicaldtherapistd(PT)dplacesdadgaitdbeltdondadclientdanddisdassistingdthemdwithdambulati
ondfromdthedbeddtodthedchair.dAsdtheydgetdupdoutdofdthedbed,dtheydreportdbeingddizzydanddbe
gindtodfall.dThedPTdcarefullydallowsdthemdtodfalldbackdtodthedbeddanddnotifiesdthedprimarydnur
se.dWhichdwrittenddocumentationdshoulddthednursedputdindthedclient'sdrecord?d
A)dClientdexperienceddorthostaticdhypotensiondwhendgettingdoutdofdbed.
B)dPTdreporteddclientdcomplaineddofddizzinessdwhendgettingdoutdofdbed,danddgaitdbeltdwasdu
seddtodallowdclientdtodfalldbackdontodthedbed.
C)dPTdnotifieddthedprimarydnursedthatdthedclientdcoulddnotdambulatedatdthisdtimedbecausedofd
dizziness.
D)dClientdhadddifficultydambulatingdfromdthedbeddtodthedchairdwhendaccompanieddbydthedPT
,dvariancedreportdcompleted.d-
dB)dPTdreporteddclientdcomplaineddofddizzinessdwhendgettingdoutdofdbed,danddgaitdbeltdwasd
useddtodallowdclientdtodfalldbackdontodthedbed.
Rationale:dThisddocumentationdprovidesdthedfactualddatadofdthedeventsdthatdoccurred.dA)Th
ednursedisdmakingdandassumptiondthatdtheddizzinessdwasdcauseddbydorthostaticdhypotensio
n.dC)dNotdalldthedpertinentdfactsdaredincludeddindthisddocumentation.
D)dAdvariancedreportdshoulddneverdbeddocumenteddindthedclient'sdrecord.
Adnewdnursedgraduatedisdcaringdfordadpostoperativedclientdwithdthedfollowingdarterialdbloodd
gasesd(ABGs):dpH,d7.30;dPCO2,d60dmmdHg;dPO2,d80dmmdHg;dbicarbonate,d24dmEq/L;dand
dO2dsaturation,d96%.dWhichdofdthesedactionsdbydthednewdgraduatedisdindicated?
A)dEncouragedthedclientdtodusedthedincentivedspirometerdanddtodcough.
B)dAdministerdoxygendbydnasaldcannula.
C)dRequestdadprescriptiondfordsodiumdbicarbonatedfromdthedhealthdcaredprovider.
D)dInformdthedchargednursedthatdnodchangesdindtherapydaredneeded.d-
dA)dEncouragedthedclientdtodusedthedincentivedspirometerdanddtodcough.
Rationale:dRespiratorydacidosisdisdcauseddbydCO2dretentiondanddimpaireddchestdexpansio
ndsecondarydtodanesthesia.dThednursedtakesdstepsdtodpromotedCO2delimination,dincludingd
maintainingdadpatentdairwaydanddexpandingdthedlungsdthroughdbreathingdtechniques.dO2dis
dnotdindicateddbecausedPo2danddoxygendsaturationdaredwithindthednormaldrange.dSodiumdbi
carbonatedisdnotdindicateddbecausedthedbicarbonatedleveldisdindthednormaldrange;dpromotin
gdexcretiondofdrespiratorydacidsdisdthedprioritydindrespiratorydacidosis.dPostdanesthesia,dthed
clientdwilldneeddinterventionsdasddescribeddindAdabovedordmaydprogressdtodadstatedofdsomno
lencedanddunresponsiveness.
Thednursedisdprovidingddietarydinstructionsdtodad68-year-
olddclientdwhodisdatdhighdriskdforddevelopmentdofdcoronarydheartddiseased(CHD).dWhichdinfo
rmationdshoulddthednursedinclude?
A)dLimitddietarydselectiondofdcholesteroldtod300dmgdperdday
B)dIncreasedintakedofdsolubledfiberdtod10dtod25dgramsdperdday.d
C)dDecreasedplantdstanolsdanddsterolsdtodlessdthand2dgrams/day.d
