Practice 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 Choices:
Correct Answer:
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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This question is from HESI RN Med-Surg Fall 2024. 15.7.2025 which contains 41 questions.
More Questions from This Exam
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?
Answer Choices:
A. "l will use a lancing device on the center of my finger pad for a drop of blood."
B. l will wash my hands with warm soapy water before sticking my finger."
C. "I will inform the healthcare provider (HCP) of my average HbA1c results weekly."
D. l will document my HbA1c results from the SMBG monitor every morning
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?
Answer Choices:
A. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
B. Decreased renin-angiotensin response related to an increase in renal blood flow.
C. Decreased portacaval pressure with greater collateral circulation.
D. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
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?
Answer Choices:
A. Bronchoscopy
B. Pulmonary function test.
C. Endotracheal intubation.
D. Chest tube insertion.
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?
Answer Choices:
A. Serum albumin.
B. Blood pH level.
C. Neutrophil count.
D. Platelet count.
A client is admitted with a history of hypertension and an acute myocardial infarction 2 years ago. The client reports, I weak and tired, so I cannot exercise at all. I feel out of breath when I walk even a short distance. Since I cannot exercise, I gaining weight. My shoes are even getting tight!" The cardiac monitor displays sinus tachycardia. Which cue should lead the nurse to further assess the client for other symptoms of right sided heart failure?
Answer Choices:
A. Lack of exercise.
B. Weakness.
C. Breathlessness.
D. Report of tight shoes.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi MedSurg
- Answer Choices: 4