HESI case study Advanced Cardiac Life Support (ACLS): Sepsis
Test Questions and Answers Rated A
the nurse is aware that the older adult client is at -Increased pain
an increased risk for surgical complications due -Dehydration - ANSWER -Dehydration
to normal physiological functions and
comobidities. Which risk factors place the older
adult client at increased risk for surgical The nurse is caring for the client who has just
complications? been extubated. What should the nurse do first,
after the client is extubated?
-Decreased respiratory muscle strength
-Increased glomerular filtration rate -Administer supplemental oxygen
-Enhanced elasticity of the arterial walls -Auscultate bilateral lung sounds
-Rigidity of the arterial walls increases the clients -Encourage cough and deep breathing
risk for complications - ANSWER - -Notify the spouse of extubation -
Decreased respiratory muscle strength ANSWER -Administer supplemental oxygen
Upon completing the clients assessment, the One hour has passed since the client was
nurse determines that the client has which extubated. Which nursing actions take priority at
surgical risk factors? (select all that apply) this time? (select all that apply)
-Metoprolol -Monitor respiratory rate
-Poor appetite -Assess cardiac rhythm
-Diabetes Mellitus -Measure blood pressure
-Albumin 3.0 g/dL -Compare bilateral pulses
-Marital status - ANSWER -Metoprolol -Instruct on mouth care - ANSWER -Monitor
Poor appetite respiratory rate
Diabetes Mellitus Assess cardiac rhythm
Albumin 3.0 g/dL
Based on the nurse's assessment, which is the
What is the priority preoperative nursing action to priority nursing action?
prevent postoperative atelectasis?
-Give acetaminophen
-Administer pain medication as needed -Administer morphine
-Instruct on incentive spirometer use -Monitor urine output
-Obtain baseline pulse saturation -Assess mental status - ANSWER -
-Turn and position every 2 hours - Administer morphine
ANSWER -Instruct on incentive spirometer
use
Based on the healthcare provider's (HCP)
prescription, the pharmacy dispenses morphine
Which is the likely reason for the elevated serum 4mg per 1mL. How many mL should the nurse
creatinine in the absence of kidney disease? administer to the client? (numerical value only. If
required, round to nearest hundredth) -
-Anemia ANSWER -0.25
-Hypertension
1/4
Test Questions and Answers Rated A
the nurse is aware that the older adult client is at -Increased pain
an increased risk for surgical complications due -Dehydration - ANSWER -Dehydration
to normal physiological functions and
comobidities. Which risk factors place the older
adult client at increased risk for surgical The nurse is caring for the client who has just
complications? been extubated. What should the nurse do first,
after the client is extubated?
-Decreased respiratory muscle strength
-Increased glomerular filtration rate -Administer supplemental oxygen
-Enhanced elasticity of the arterial walls -Auscultate bilateral lung sounds
-Rigidity of the arterial walls increases the clients -Encourage cough and deep breathing
risk for complications - ANSWER - -Notify the spouse of extubation -
Decreased respiratory muscle strength ANSWER -Administer supplemental oxygen
Upon completing the clients assessment, the One hour has passed since the client was
nurse determines that the client has which extubated. Which nursing actions take priority at
surgical risk factors? (select all that apply) this time? (select all that apply)
-Metoprolol -Monitor respiratory rate
-Poor appetite -Assess cardiac rhythm
-Diabetes Mellitus -Measure blood pressure
-Albumin 3.0 g/dL -Compare bilateral pulses
-Marital status - ANSWER -Metoprolol -Instruct on mouth care - ANSWER -Monitor
Poor appetite respiratory rate
Diabetes Mellitus Assess cardiac rhythm
Albumin 3.0 g/dL
Based on the nurse's assessment, which is the
What is the priority preoperative nursing action to priority nursing action?
prevent postoperative atelectasis?
-Give acetaminophen
-Administer pain medication as needed -Administer morphine
-Instruct on incentive spirometer use -Monitor urine output
-Obtain baseline pulse saturation -Assess mental status - ANSWER -
-Turn and position every 2 hours - Administer morphine
ANSWER -Instruct on incentive spirometer
use
Based on the healthcare provider's (HCP)
prescription, the pharmacy dispenses morphine
Which is the likely reason for the elevated serum 4mg per 1mL. How many mL should the nurse
creatinine in the absence of kidney disease? administer to the client? (numerical value only. If
required, round to nearest hundredth) -
-Anemia ANSWER -0.25
-Hypertension
1/4
