PN Perioperative Care HESI Case Study, questions with rated solutions

PN Perioperative Care HESI Case Study, questions with rated solutions Which vital sign requires follow-up by the PN? A. BP of 160/80. What is the most important nursing action for the PN to implement? D. Verify that the client has stopped taking the warfarin (Coumadin) prior to surgery per the HCP's instruction. Which serum lab requires follow-up action by the PN? B. WBC of 14,000/mm3. What is the best action for the PN to implement first? C. Demonstrate the deep breathing and coughing technique again. How should the PN respond? C. "Pressure ulcers are one of many problems that can occur from prolonged bedrest." How should the PN respond? D. "The pump has a control device that prevents you from taking too much medication." What is the best action for the PN to take when Ms. Burke begins to cry? A. Sit quietly with the client. How should the PN respond? C. "It sounds as if you went through a difficult time when your father died." Which question is most important for the PN to ask Ms. Burke upon arrival to the surgery center? A. "Have you had anything to eat or drink since midnight?" What action should the PN take? A. Ask Ms. Burke if she has received sufficient information to sign the consent form. What action should the PN implement? C. Confirm that the left hip is the site of the scheduled surgery. Which nursing diagnosis has the highest priority at this time? C. Risk for perioperative positioning injury. What action should the PN take during the time out? C. Participate in the review of the scheduled procedure. What action should the PN implement first? A. Position the client on her side. How should the PN document this finding? B. Left hip dressing clean, dry, and intact. True or False: The PN should notify the RN that the IV is not infusing. A. True. What action should the PN implement? D. Obtain an IV infusion pump and collect the correct tubing. To observe Ms. Burke for atelectasis, what action should the PN take? A. Auscultate the client's breath sounds. What action should the PN implement in response to this finding? A. Document the finding in the client record. What action should the PN implement? C. Observe the linens under the hip. True or False: The PN can assess a wound drain and the drainage system. B. False. What lab data is important for the PN to report to the surgeon? B. Hemoglobin and Hematocrit. What action should the PN take? B. Collect the correct tubing for transfusion of packed cells while the UAP completes the client's personal care. Before the RN begins Ms. Burke's transfusion of packed red blood cells, what action should the PN expect to be assigned by the RN? A. Obtain a liter bag of normal saline from the medication dispenser. In response to these remarks, the PN identifies which nursing diagnosis to add to Ms. Burke's plan of care? B. Disturbed personal identity. What is the best rationale for the inclusion of this intervention in Ms. Burke's plan of care? D. Increased mobility will promote an improved sense of control.