Question

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Answer 1

Correct Answers:

Check the abdominal surgical dressing.

Rationale :

🌟 A sudden drop in blood pressure following major abdominal surgery raises concern for internal or external bleeding.

🌟 The nurse’s first action should be to assess the surgical site and dressing for evidence of hemorrhage, such as fresh bleeding, saturation, or distention.

🌟 Postoperative hemorrhage is a life-threatening complication that requires rapid detection and intervention to prevent hypovolemic shock.

🌟 While monitoring BP trends and increasing frequency of assessments are important, they do not address the cause of the hypotension.

🌟 Encouraging deep breathing is unrelated to the acute drop in BP and does not address the immediate risk.

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Answer 2

Correct Answers:

l will wash my hands with warm soapy water before sticking my finger."

Rationale :

🌟 Washing hands with warm soapy water before self-monitoring blood glucose (SMBG) prevents infection and removes contaminants (like food residue) that may alter results.

🌟 The side of the finger pad (not the center) is recommended for lancing, as it is less painful and provides an adequate blood sample.

🌟 HbA1c is not measured with a home SMBG monitor—it is a lab test done about every 3 months to evaluate long-term glycemic control, not a daily measure.

🌟 Clients do not need to report HbA1c weekly; instead, results are reviewed during regular clinic visits with the provider.

🌟 Effective teaching is demonstrated when the client identifies safe and accurate techniques for daily blood glucose monitoring at home.

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Answer 3

Correct Answers:

Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

Rationale :

🌟 In cirrhosis, the damaged liver has reduced ability to synthesize albumin, the main plasma protein responsible for maintaining colloidal oncotic pressure in the vascular system.

🌟 Hypoalbuminemia leads to fluid shifting out of the intravascular space into the interstitial tissues and peritoneal cavity, causing peripheral edema and ascites.

🌟 Ascites is further aggravated by portal hypertension and activation of the renin-angiotensin-aldosterone system (RAAS), but the primary mechanism behind massive fluid accumulation is the loss of oncotic pressure due to low albumin.

🌟 Without enough albumin, the vascular system cannot "hold" fluid, so it leaks into dependent tissues (legs, feet) and the abdominal cavity.

🌟 Correcting hypoalbuminemia (e.g., through nutrition, albumin infusions, or managing underlying liver disease) is key to controlling ascites and edema.

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Answer 4

Correct Answers:

Chest tube insertion.

Rationale :

🌟 Absent breath sounds on one side with increasing dyspnea following trauma suggests a pneumothorax or hemothorax, where air or blood has accumulated in the pleural space and collapsed the lung.

🌟 The immediate treatment is chest tube insertion, which drains the air (pneumothorax) or blood (hemothorax), re-expands the lung, and restores ventilation.

🌟 Bronchoscopy is used for airway obstruction or foreign body removal, not for pleural space collapse.

🌟 Pulmonary function tests are outpatient diagnostic studies, not appropriate for acute emergency management.

🌟 Endotracheal intubation may be required if the client cannot maintain oxygenation, but the priority is to re-expand the lung via chest tube.

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Answer 5

Correct Answers:

Neutrophil count.

Rationale :

🌟 Purulent drainage from burn wounds is a strong indicator of infection, a major complication in clients with extensive burns due to skin barrier loss.

🌟 The neutrophil count (a type of white blood cell) is a key laboratory marker of infection and inflammation. Elevated neutrophils suggest an active infection, while low counts may indicate immunosuppression.

🌟 Monitoring neutrophil levels helps the nurse provide the provider with objective evidence to support clinical findings of infection.

🌟 Serum albumin reflects nutritional status, platelet count reflects clotting ability, and blood pH level reflects acid-base balance—but none directly confirm infection.

🌟 Since infection in burn patients can rapidly progress to sepsis, checking the neutrophil count is most relevant before reporting to the HCP.

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Answer 6

Correct Answers:

Report of tight shoes.

Rationale :

🌟 Right-sided heart failure is commonly associated with systemic venous congestion, leading to peripheral edema.

🌟 The client’s statement that their shoes are getting tight suggests swelling in the feet and ankles, a hallmark sign of fluid retention due to right ventricular dysfunction.

🌟 Right-sided failure often presents with jugular venous distention, hepatomegaly, ascites, and peripheral edema, all linked to backup of blood in the systemic circulation.

🌟 While weakness, lack of exercise, and breathlessness are consistent with left-sided heart failure (pulmonary congestion and decreased cardiac output), tight shoes point directly to right-sided involvement.

🌟 Recognizing this cue helps the nurse assess for additional right-sided findings and provide timely management.

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Answer 7

Correct Answers:

Lumbar puncture.

Rationale :

🌟 The definitive diagnostic test for bacterial meningitis is a lumbar puncture (spinal tap), which allows collection and analysis of cerebrospinal fluid (CSF).

🌟 CSF findings typically include elevated white blood cells, decreased glucose, and increased protein, confirming infection.

🌟 A CT or MRI may be performed before lumbar puncture if increased intracranial pressure (ICP) or a mass lesion is suspected, but they do not confirm meningitis.

🌟 Skull radiography has no role in meningitis diagnosis, as it does not visualize brain tissue or CSF.

🌟 Prompt lumbar puncture is critical for early detection, initiation of antibiotics, and preventing life-threatening complications such as sepsis or brain damage.

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Answer 8

Correct Answers:

Breathe deeply, followed by coughing up the sputum.

Rationale :

🌟 The proper method for collecting a sputum specimen is to have the client take several deep breaths and then cough deeply to bring up secretions from the lungs, not just saliva.

🌟 This technique ensures the sample contains tracheobronchial secretions for accurate microbiological or cytological analysis.

🌟 Sputum specimens are best obtained in the early morning, before eating or drinking, when secretions have accumulated overnight.

🌟 Clients should perform oral care before collection to reduce contamination from food particles or oral bacteria.

🌟 Fluid intake should not be restricted, as hydration helps loosen secretions and makes specimen collection easier.

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Answer 9

Correct Answers:

Skin condition of lower extremities.
Sensation in feet and legs.
Visual acuity.
Serum creatinine and blood urea nitrogen (BUN).

Rationale :

✅ B. Skin condition of lower extremities

🌟 Long-term diabetes can cause peripheral vascular disease and poor wound healing, increasing the risk of ulcers, infections, and gangrene.

🌟 Assessing the skin integrity of lower extremities helps identify early signs of breakdown or infection that may lead to amputations.

🌟 Regular foot and skin checks are a cornerstone of diabetic complication prevention.

✅ C. Sensation in feet and legs

💎 Peripheral neuropathy is a common complication of diabetes due to long-term nerve damage from poor glycemic control.

💎 Assessment of sensation helps detect numbness, tingling, or loss of protective sensation, which predisposes clients to injuries and undetected infections.

💎 Early recognition allows for teaching protective foot care practices to reduce complications.

✅ D. Visual acuity

🔷 Diabetes is a leading cause of retinopathy, cataracts, and glaucoma, which can lead to blindness if undetected.

🔷 Regular visual acuity testing and referral to an ophthalmologist help detect microvascular complications early.

🔷 Monitoring vision changes is critical for maintaining independence and safety in older adults.

✅ E. Serum creatinine and blood urea nitrogen (BUN)

🟡 Diabetic nephropathy is a serious long-term complication that can progress to chronic kidney disease or end-stage renal failure.

🟡 Monitoring BUN and creatinine assesses kidney function and detects renal impairment early.

🟡 Lab evaluation is combined with urine albumin testing to track disease progression.

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Answer 10

Correct Answers:

Administer a stool softener

Rationale :

🌟 After cataract extraction with lens implant, avoiding activities that increase intraocular pressure (IOP) is critical for protecting the surgical site.

🌟 Straining during bowel movements can sharply elevate IOP, increasing the risk of wound dehiscence, hemorrhage, or displacement of the new lens implant.

🌟 Stool softeners reduce the risk of constipation and straining, supporting a safe recovery.

🌟 Other important discharge teachings include avoiding bending, lifting, or vigorous coughing/sneezing, and wearing an eye shield at night for protection.

🌟 Monitoring the unaffected (right) eye pupil response, coughing exercises, or lying flat are not specific to cataract post-op care and may increase risk instead of promoting healing.

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HESI RN Med-Surg Fall 2024.

No.

1 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 :
A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 :
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

4 :
A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent from

5 :
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?

7 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

8 :
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum?

9 :
An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply.

10 :
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

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HESI RN Med-Surg Fall 2024.

No.

1 : One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 : A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 : The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

4 : A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent from

5 : While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?

7 : The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

8 : The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum?

9 : An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply.

10 : Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

1 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 :
A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 :
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

4 :
A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent from

5 :
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?

7 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

8 :
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum?

9 :
An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply.

10 :
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?