Question

One hour after major abdominal surgery, a client in the post anesthesia 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 drop in blood pressure soon after surgery suggests possible hemorrhage or bleeding.

🔹 The first priority is to inspect the surgical site and dressing for signs of active bleeding.

🔹 Encouraging deep breathing may help oxygenation but does not address the cause of hypotension.

🔹 Reviewing baseline BP trends delays urgent intervention.

🔹 Increasing frequency of assessments without investigating the cause risks missing a life-threatening complication.

🔹 Post-op hemorrhage is the most urgent complication to rule out.

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Answer 2

Correct Answers:

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

Rationale :

🟢 Proper hand hygiene prevents infection and ensures accurate self-monitoring blood glucose (SMBG) results.

🟢 Warm water also promotes blood flow, making it easier to obtain a drop of blood.

🟢 The lancet should be applied to the side of the fingertip, not the center, to reduce pain and promote better blood flow.

🟢 HbA1c is checked by a lab every 3 months, not daily or weekly.

🟢 SMBG monitors do not provide HbA1c values—those reflect long-term glucose control.

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Answer 3

Correct Answers:

Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

Rationale :

🔹 In cirrhosis, the damaged liver cannot synthesize enough albumin, leading to hypoalbuminemia.

🔹 Albumin normally maintains colloidal oncotic pressure, keeping fluid within the vascular space.

🔹 Low albumin → fluid leaks into the peritoneal cavity (ascites) and interstitial spaces (edema).

🔹 Hyperaldosteronism (Option D) does occur in cirrhosis but the primary mechanism for massive ascites and generalized edema is hypoalbuminemia.

🔹 Portal hypertension contributes, but oncotic pressure loss is the direct mechanism for fluid accumulation.

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Answer 4

Correct Answers:

Chest tube insertion.

Rationale :

🟠 Findings of dyspnea and absent breath sounds on one side after trauma indicate pneumothorax or hemothorax.

🟠 A chest tube is required to evacuate air/blood and re-expand the lung.

🟠 Bronchoscopy is for airway obstruction, not collapsed lung.

🟠 Pulmonary function tests are outpatient diagnostics, not emergent.

🟠 Intubation supports the airway but does not treat pneumothorax.

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Answer 5

Correct Answers:

Neutrophil count.

Rationale :

🔵 Purulent drainage indicates possible infection in burn wounds.

🔵 Neutrophils (a type of WBC) are the body’s first line of defense against bacterial infection.

🔵 Evaluating neutrophil count helps confirm or rule out systemic infection/sepsis.

🔵 Serum albumin relates to nutrition, not acute infection.

🔵 Blood pH indicates acid-base balance, not infection.

🔵 Platelet count reflects coagulation, not wound infection.

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Answer 6

Correct Answers:

Report of tight shoes.

Rationale :

🟢 Right-sided heart failure causes systemic venous congestion → peripheral edema, ascites, weight gain.

🟢 The client’s tight shoes indicate worsening edema in the lower extremities.

🟢 Weakness and breathlessness are more typical of left-sided HF (low cardiac output and pulmonary congestion).

🟢 Lack of exercise is nonspecific and not diagnostic.

🟢 Edema and weight gain are hallmark cues for right-sided HF.

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Answer 7

Correct Answers:

Lumbar puncture.

Rationale :

🔹 Lumbar puncture (LP) is the gold standard diagnostic procedure for bacterial meningitis, as it allows direct analysis of cerebrospinal fluid (CSF).

🔹 CSF findings in bacterial meningitis typically show: elevated WBCs, low glucose, high protein, and possible positive Gram stain/culture.

🔹 Skull radiography is not useful for meningitis—it only shows bone structures.

🔹 CT/MRI may be done first if there are signs of increased intracranial pressure or focal neuro deficits, but LP is the definitive diagnostic test.

🔹 Preparing the client involves ensuring informed consent, positioning in lateral recumbent with knees to chest, and maintaining aseptic technique.

🔹 Early LP ensures rapid confirmation and timely antibiotic therapy, which reduces morbidity and mortality.

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Answer 8

Correct Answers:

Breathe deeply, followed by coughing up the sputum.

Rationale :

🔹 A sputum specimen should be obtained by deep breathing followed by forceful coughing to bring up secretions from the lower respiratory tract, not saliva.

🔹 Restricting fluids is not correct—hydration actually helps loosen secretions and makes collection easier.

🔹 Mouth care should be performed prior to reduce contamination from oral bacteria or food particles.

🔹 The best time to obtain sputum is early in the morning, not at bedtime, because secretions accumulate overnight.

🔹 Proper technique ensures that the specimen is valid for culture, cytology, or TB testing.

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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 :

🔹 Skin condition of lower extremities → Clients with long-term type 2 DM are at risk for poor wound healing, peripheral vascular disease, and diabetic foot ulcers. Inspecting the skin detects early breakdown.

🔹 Sensation in feet and legs → Peripheral neuropathy is a common chronic complication of DM. Assessing for paresthesia, numbness, or burning identifies nerve damage.

🔹 Visual acuity → Diabetic retinopathy and cataracts are leading causes of blindness in older adults with DM. Annual eye exams are essential.

🔹 Serum creatinine and BUN → Evaluate kidney function, as DM is the most common cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD).

🔹Signs of respiratory tract infection → Not a specific long-term complication of DM. While infections are more common, this is not the primary focus for assessing chronic complications.

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Answer 10

Correct Answers:

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

Rationale :

🔹 Skin condition of lower extremities → monitors for ulcers, poor healing, and vascular disease.

🔹 Sensation in feet/legs → assesses for peripheral neuropathy (burning, numbness).

🔹 Visual acuity → checks for diabetic retinopathy and cataracts.

🔹 Serum creatinine & BUN → evaluate renal function since DM can cause nephropathy.

🔹 Respiratory tract infections are common but not a long-term complication marker.

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HESI RN Med-Surg Fall 2024. 15.7.2025

No.

1 :
One hour after major abdominal surgery, a client in the post anesthesia 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 for?

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

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HESI RN Med-Surg Fall 2024. 15.7.2025

No.

1 : One hour after major abdominal surgery, a client in the post anesthesia 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 for?

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

1 :
One hour after major abdominal surgery, a client in the post anesthesia 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 for?

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