Rédigé par des étudiants ayant réussi Disponible immédiatement après paiement Lire en ligne ou en PDF Mauvais document ? Échangez-le gratuitement 4,6 TrustPilot
logo-home
Document preview thumbnail
Aperçu 4 sur 325 pages
Examen

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

Document preview thumbnail
Aperçu 4 sur 325 pages

HESI HEALTH ASSESSMENT NURSING RN V1 145 Questions with

Aperçu du contenu

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

Livre connecté
 image
Éditeur: 2021 ISBN: 9781975172572 Édition: Inconnu

Infos sur le Document

Publié le
26 février 2025
Nombre de pages
325
Écrit en
2024/2025
Type
Examen
Contenu
Questions et réponses
19,05 €

Mauvais document ? Échangez-le gratuitement Dans les 14 jours suivant votre achat et avant le téléchargement, vous pouvez choisir un autre document. Vous pouvez simplement dépenser le montant à nouveau.
Rédigé par des étudiants ayant réussi
Disponible immédiatement après paiement
Lire en ligne ou en PDF

Seller avatar
Les scores de réputation sont basés sur le nombre de documents qu'un vendeur a vendus contre paiement ainsi que sur les avis qu'il a reçu pour ces documents. Il y a trois niveaux: Bronze, Argent et Or. Plus la réputation est bonne, plus vous pouvez faire confiance sur la qualité du travail des vendeurs.
GOLDENNTESTBANKS
4,7
(720)
Vendu
13
Abonnés
1
Éléments
460
Dernière vente
3 mois de cela


Avis d'acheteurs vérifiés




Pourquoi les étudiants choisissent Stuvia

Créé par d'autres étudiants, vérifié par les avis

Une qualité sur laquelle compter : rédigé par des étudiants qui ont réussi et évalué par d'autres qui ont utilisé ce document.

Le document ne convient pas ? Choisis un autre document

Aucun souci ! Tu peux sélectionner directement un autre document qui correspond mieux à ce que tu cherches.

Paye comme tu veux, apprends aussitôt

Aucun abonnement, aucun engagement. Paye selon tes habitudes par carte de crédit et télécharge ton document PDF instantanément.

Student with book image

“Acheté, téléchargé et réussi. C'est aussi simple que ça.”

Alisha Student

Vous travaillez sur vos références ?

Créez des citations précises en APA, MLA et Harvard avec notre générateur de sources gratuit.

Vous travaillez sur vos références ?

Foire aux questions