HESI HEALTH ASSESSMENT NURSING RN V1 145 Questions with answers.pdf

ExtracCreditcHESIcModulec9


1. Questions
1. 1.ID:c9477047208
Acclientcwhochascundergonecabdominalcsurgeryccallscthecnursecandcreportscthatc
shecjustcfeltc“somethingcgivecway”cincthecabdominalcincision.cThecnursecchecksct
hecincisioncandcnotescthecpresencecofcwoundcdehiscence.cThecnursecshouldctak
ecwhichcimmediatecaction?
A. Documentcthecfindings
B. Contactcthechealthccarecprovider
C. Placecthecclientcincacsupinecpositioncwithctheclegscflat
D. Covercthecabdominalcwoundcwithcacsterilecdressingcmoistenedc
withcsterilecsalinecsolutioncCorrect
Rationale:cWoundcdehiscenceciscthecdisruptioncofcacsurgicalcincisioncorcwound.cW
hencdehiscencecoccurs,cthecnursecimmediatelycplacescthecclientcincaclowcFowler’
scpositioncorcsupinecwithctheckneescbentcandcinstructscthecclientctocliecquietly.cThe
secactionscwillcminimizecprotrusioncofcthecunderlyingctissues.cThecnursecthenccov
erscthecwoundcwithcacsterilecdressingcmoistenedcwithcsterilecsaline.cThechealthcca
recproviderciscnotified,candcthecnursecdocumentscthecoccurrencecandcthecnursingc
actionscthatcwerecimplementedcincresponse.
Test-
TakingcStrategy:cNotecthecstrategiccwordc“immediate.”cVisualizecthiscoccurrencec
andcrecallcthatcthecprimarycconcerncwhencwoundcdehiscencecoccursciscthecprotru
sioncofcunderlyingctissues.cThiscwillcdirectcyouctoctheccorrectcoption.cReviewcthecn
ursingcactionsctocbectakencimmediatelycinctheceventcofcwoundcdehiscence
LevelcofcCognitivecAbility:cApplying
ClientcNeeds:cPhysiologicalcIntegrity
IntegratedcProcess:cNursingcProcess/Implementation
ContentcArea:cPerioperativecCare
GiddenscConcepts:cCaregiving,cTissuecIntegritycH
ESIcConcepts:cCaregiving,cTissuecIntegrity
Reference:cLewis,cS.,cDirksen,cS.,cHeitkemper,cM.,c&cBucher,cL.
(2014).cMedical-
surgicalcnursing:cAssessmentcandcmanagementcofcclinicalcproblemsc(9thc ed.,cp.c1
80).
Awarded
cSt.cLouis:
c1.0cpoints
cMosby.
coutcofc1.0cpossiblecpoints.



2. 2.ID:c9477054249
Acclientcwhocjustcreturnedcfromcthecrecoverycroomcaftercactonsillectomycandc
adenoidectomyciscrestlesscandcthecpulsecrateciscincreased.cAscthecnursecco
ntinuescthecassessment,cthecclientcbeginsctocvomitcaccopiouscamountcofcbrig
ht-redcblood.cThecnursecshouldctakecwhichcimmediatecaction?
A. NotifycthecsurgeoncCorrect
B. Continuecthecassessment

, ExtracCreditcHESIcModulec9


C. Checkcthecclient’scbloodcpressure
D. Obtaincacflashlight,cgauze,candcaccurvedchemostat
Rationale:cHemorrhageciscacpotentialccomplicationcafterctonsillectomycandcadeno
idectomy.cIfcthecclientcvomitscaclargecamountcofcbright-
redcbloodcorcthecpulsecratecincreasescandcthecpatientciscrestless,cthecnursecmustc
notifycthecsurgeoncimmediately.cThecnursecshouldcobtaincaclight,cmirror,cgauze,cc
urvedchemostat,candcwastecbasinctocfacilitatecexaminationcofcthecsurgicalcsite.cTh
ecnursecshouldcalsocgathercadditionalcassessmentcdata,cbutcthecsurgeoncmustcbe
ccontactedcimmediately.

Test-
TakingcStrategy:cNotecthecstrategiccword,cimmediate.cNotingcthecwordsc“brigh
t-
redcblood”cwillcassistcincdirectingcyouctoctheccorrectcoption.cRemembercthatcthe
cpresencecofcbright-

redcbloodcindicatescactivecbleeding.cReviewcthecnursingcactionsctocbectakenci
mmediatelycwhencbleedingcoccurscaftercactonsillectomycandcadenoidectomy
LevelcofcCognitivecAbility:cApplying
ClientcNeeds:cPhysiologicalcIntegrity
IntegratedcProcess:cNursingcProcess/Implementation
ContentcArea:cCriticalcCare:cEmergencycSituation/Management
GiddenscConcepts:cCollaboration,cClotting
HESIcConcepts:cCollaboration/ManagingcCare,cPerfusion-Clotting
Awardedc1.0
Reference: cpointscoutcof
cIgnatavicius, c1.0
cD., c&cpossible
cWorkman,cpoints.
cM.c(2013).cMedical-

surgicalcnursing:cPatient-
3. 3.ID:c9477051455
centeredccollaborativeccare.c(7thc ed.,cp.c644).cSt.cLouis:cSaunders.
Acclientcwhochascjustcundergonecsurgerycsuddenlycexperiencescchestcpain,cdysp
nea,candctachypnea.cThecnursecsuspectscthatcthecclientchascacpulmonarycemboli
smcandcimmediatelycsetscaboutctoctakecwhichcaction?
A. Preparingcthecclientcforcacperfusioncscan
B. Attachingcthecclientctocaccardiaccmonitor
C. AdministeringcoxygencbycwaycofcnasalccannulacCorrect
D. Ensuringcthatcthecintravenousc(IV)clineciscpatent
Rationale:cPulmonarycembolismciscaclife-
threateningcemergency.cOxygenciscimmediatelycadministeredcnasallyctocreliev
echypoxemia,crespiratorycdistress,candccentralccyanosis,candcthe
healthccarecprovideriscnotified.cIVcinfusionclinescarecneededctocadministercmedica
tionscorcfluids.cAcperfusioncscan,camongcotherctests,cmaycbecperformed.cThecelect
rocardiogramciscmonitoredcforcthecpresencecofcdysrhythmias.
Additionally,cacurinaryccathetercmaycbecinsertedcandcbloodcforcarterialcbloodcgasc
determinationscdrawn.cThecimmediatecpriority,chowever,ciscthecadministrationcofc
oxygen.
Test-TakingcStrategy:cFocusconcthecclient’scdiagnosiscandcusecthecskillscof

, ExtracCreditcHESIcModulec9


prioritizing.cUsecthecABCsc(airway,cbreathing,candccirculation)ctocfindctheccorrectco
ption.cReviewcthecnursingcactionsctocbectakencimmediatelycinctheceventcofcpulmo
narycembolism
LevelcofcCognitivecAbility:cApplying
ClientcNeeds:cPhysiologicalcIntegrity
IntegratedcProcess:cNursingcProcess/Implementation
ContentcArea:cCriticalcCare:cEmergencycSituation/Management
GiddenscConcepts:cPerfusion,cClotting
HESIcConcepts:cOxygenation/GascExchange,cPerfusion-Clotting
Reference:cLewis,cS.,cDirksen,cS.,cHeitkemper,cM.,c&cBucher,cL.
(2014).cMedical-
surgicalcnursing:cAssessmentcandcmanagementcofcclinicalcproblemsc(9thc ed.,cp.c5
Awarded
52). c1.0cpoints
cSt.cLouis: coutcofc1.0cpossiblecpoints.
cMosby.



4. 4.ID:c9477051498
Acnurseciscassessingcacclientcwhochascacclosedcchestctubecdrainagecsystem.c
Thecnursecnotescconstantcbubblingcincthecwatercsealcchamber.cWhatcactionsc
shouldcthecnursectake?c(Selectcallcthatcapply).
A. Clampcthecchestctube
B. Changcthecdrainagecsystem
C. AssesscthecsystemcforcancexternalcaircleakcCorrect
D. Reducecthecdegreecofcsuctioncbeingcapplied
E. Documentcassessmentcfindings,cactionsctaken,candcclientc
responsecCorrect
Rationale:cConstantcbubblingcincthecwatercsealcchambercofcacclosedcchestctubec
drainagecsystemcmaycindicatecthecpresencecofcancaircleak.cThecnursecwouldcass
esscthecchestctubecsystemcforcthecpresencecofcancexternalcaircleakcifcconstantcbu
bblingcwerecnotedcincthiscchamber.cIfcancexternalcaircleakciscnotcpresentcandcthec
aircleakciscacnewcoccurrence,cthechealthccarecproviderciscnotifiedcimmediately,cb
ecausecancaircleakcmaycbecpresentcincthecpleuralcspace.cLeakagecandctrappingc
ofcaircincthecpleuralcspaceccancresultcincactensioncpneumothorax.cClampingcthecc
hestctubeciscincorrect.cAdditionally,cacchestctubeciscnotcclampedcunlesscthischasc
beencspecificallycprescribedcincthecagency’scpoliciescandcprocedures.cChanging
cthecdrainagecsystemcwillcnotcalleviatecthecproblem.cReducingcthecdegreecofcsuc

tioncbeingcappliedcwillcnotcaffectcthecbubblingcincthecwatercsealcchambercandccou
ldcbecharmful.cThecnursecwouldcdocumentcthecassessmentcfindingscandcinterve
ntionsctakencincthecclient’scmedicalcrecord.
Test-
TakingcStrategy:cFocusconcthecdatacincthecquestion,cnotingcthatcthereciscbubblingc
incthecwatercsealcchamber.cUsecknowledgecregardingcthecprioritycactionscincthecc
arecofcacclosedcchestctubecdrainagecsystem.cRecallingcthatcthis
maycindicatecancaircleakcwillcdirectcyouctoctheccorrectcoptions.cReviewcthe

, ExtracCreditcHESIcModulec9


nursingcactionsctocbectakencimmediatelycinctheceventcthatccomplicationscofcacclos
edcchestctubecdrainagecsystemcoccur
LevelcofcCognitivecAbility:cApplying
ClientcNeeds:cPhysiologicalcIntegrity
IntegratedcProcess:cNursingcProcess/Implementation
ContentcArea:
CriticalcCare:cEmergencycSituation/Management
GiddenscConcepts:cCarecCoordination,cGascExchange
HESIcConcepts:cNursingcInterventions,cOxygenation/GascExchange
Reference:cLewis,cS.,cDirksen,cS.,cHeitkemper,cM.,c&cBucher,cL.
(2014).cMedical-
surgicalcnursing:cAssessmentcandcmanagementcofcclinicalcproblemsc(9thc ed.,cp.c5
Awarded
46). c2.0cpoints
cSt.cLouis: coutcofc2.0cpossiblecpoints.
cMosby.



5. 5.ID:c9477055619
Acnursecischelpingcacclientcwithcacclosedcchestctubecdrainagecsystemcgetcoutcofc
bedcandcintocacchair.cDuringcthectransfer,cthecchestctubecisccaughtconctheclegcofct
hecchaircandcdislodgedcfromcthecinsertioncsite.cWhatciscthecimmediatecnursingca
ction?
A. Reinsertcthecchestctube
B. Contactcthechealthccarecprovider
C. Transfercthecclientcbackctocbed
D. CovercthecinsertioncsitecwithcacsterilecocclusivecdressingcCorrect
Rationale:cIfcacchestctubeciscdislodgedcfromcthecinsertioncsite,cthecnursecimmediat
elyccoverscthecsitecwithcsterilecocclusivecdressing.cThecnursecthencperformscacres
piratorycassessment,chelpscthecclientcbackcintocbed,candccontactscthechealthccare
cprovider.cThecnursecdoescnotcreinsertcthecchestctube.cThechealthccarecprovider

willcreinsertcthecchestctubecascnecessary.
Test-
TakingcStrategy:cNotecthecstrategiccwordc“immediate.”cEliminatecthecoptioncthatci
nvolvescreinsertioncofcthecchestctubecfirst,cbecausecacnurseciscnotctrainedctocinsert
cacchestctube.cTocselectcfromcthecremainingcoptions,cfocusconcthecsubject,cdislodg

mentcofcacchestctubecfromcitscinsertioncsite,candcrecallctheccomplicationscassociat
edcwithcthiscoccurrence;cthiscwillcdirectcyouctoctheccorrectcoption.
Reviewcthecnursingcactionsctocbectakencimmediatelycinctheceventcofccom
plicationscassociatedcwithcacclosedcchestctubecdrainagecsystemcLevelcof
cCognitivecAbility:cApplying

ClientcNeeds:cPhysiologicalcIntegrity
IntegratedcProcess:cNursingcProcess/Implementation
ContentcArea:
CriticalcCare:cEmergencycSituation/Management
GiddenscConcepts:cCarecCoordination,cGascExchange