HESI Case Studies Fall Exam Questions And Answers (Guaranteed A+)

©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 1 | P a g e HESI Case Studies Fall Exam Questions And Answers (Guaranteed A+) The nurse reviews the client's medications. The client indicates that she has been taking two medications; hydrochlorothiazide, a diuretic, and warfarin , an anticoagulant, every day for more than a year. Which vital sign requires follow-up by the nurse? BP of 160/88 mmHg. Pulse of 68 beats/min. Respirations of 14 breaths/min. Temperature of 97.2° F (36.2° C). - answerBP of 160/88 mmHg. This blood pressure is elevated and requires further action by the nurse. What nursing action is most important? ©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 2 | P a g e Observe the appearance of the client's oral mucosa. Assess the client for any signs of excessive bruising. Review common side effects of each of the medications. Explain the need to withhold the warfarin prior to surgery. - answerExplain the need to withhold the warfarin prior to surgery. Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped. Which serum lab value requires follow-up by the nurse? Sodium of 135 mEq/L (135 mmol/L). WBC of 14,000/μL (4.0 x 109/L). Creatinine of 0.7 mg/dl (61.9 mmol/L). Hemoglobin of 14 g/dL (140 g/L). - answerWBC of 14,000/μL (4.0 x 109/L). ©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 3 | P a g e The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value. Preoperative Teaching The nurse talks with the client about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. The client performs a return demonstration by breathing in deeply through their mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement? Advise the client to avoid pursing her lips when exhaling. Remind the client to cough after taking 2 to 3 breaths. Demonstrate the deep breathing and coughing technique again. Document successful completion of the return demonstration. - answerDemonstrate the deep breathing and coughing technique again. ©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 4 | P a g e The client has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client. When the nurse begins teaching about the benefits of early mobilization following surgery, the client states, "Oh, I know if I stay in bed very long I will get bedsores." How should the nurse respond? "Getting a bedsore is very serious. Sometimes people die from infected bedsores." "The nurses will make sure you do not stay in bed long enough to get bedsores." "Bedsores are one of many problems that can occur from prolonged bedrest." "Those are now called pressure ulcers because they are caused by pressure." - answer"Bedsores are one of many problems that can occur from prolonged bedrest." This response acknowledges the client's previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis. ©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 5 | P a g e The nurse discusses postoperative pain management with the client and explains the use of a patient-controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself, since they will be sleepy after surgery. How should the nurse respond? "You will only use the PCA pump for the first 24 hours after surgery." "The surgeon will prescribe the dose of medication that is correct for you." "I will tell the surgeon that you prefer that the nurses administer your pain medicine." "The pump has a control device that prevents you from taking too much medicine." - answerThe pump has a control device that prevents you from taking too much medicine." This response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery. Therapeutic Communication While discussing postoperative pain management strategies with the client, the nurse observes them begin to cry.