HESI case study Advanced Cardiac Life Support (ACLS):
Sepsis
the nurse is aware that the older adult client is at an increased risk for surgical
complications due to normal physiological functions and comobidities. Which risk factors
place the older adult client at increased risk for surgical complications?
-Decreased respiratory muscle strength
-Increased glomerular filtration rate
-Enhanced elasticity of the arterial walls
-Rigidity of the arterial walls increases the clients risk for complications
Decreased respiratory muscle strength
Upon completing the clients assessment, the nurse determines that the client has which
surgical risk factors? (select all that apply)
-Metoprolol
-Poor appetite
-Diabetes Mellitus
-Albumin 3.0 g/dL
-Marital status
Metoprolol
Poor appetite
Diabetes Mellitus
Albumin 3.0 g/dL
What is the priority preoperative nursing action to prevent postoperative atelectasis?
-Administer pain medication as needed
-Instruct on incentive spirometer use
-Obtain baseline pulse saturation
-Turn and position every 2 hours
Instruct on incentive spirometer use
Which is the likely reason for the elevated serum creatinine in the absence of kidney
disease?
-Anemia
-Hypertension
-Increased pain
-Dehydration
Dehydration
The nurse is caring for the client who has just been extubated. What should the nurse
do first, after the client is extubated?
-Administer supplemental oxygen
-Auscultate bilateral lung sounds
, -Encourage cough and deep breathing
-Notify the spouse of extubation
Administer supplemental oxygen
One hour has passed since the client was extubated. Which nursing actions take priority
at this time? (select all that apply)
-Monitor respiratory rate
-Assess cardiac rhythm
-Measure blood pressure
-Compare bilateral pulses
-Instruct on mouth care
Monitor respiratory rate
Assess cardiac rhythm
Based on the nurse's assessment, which is the priority nursing action?
-Give acetaminophen
-Administer morphine
-Monitor urine output
-Assess mental status
Administer morphine
Based on the healthcare provider's (HCP) prescription, the pharmacy dispenses
morphine 4mg per 1mL. How many mL should the nurse administer to the client?
(numerical value only. If required, round to nearest hundredth)
0.25
Upon reviewing the remaining postoperative prescriptions and comparing with
preoperative prescriptions, the nurse realizes that the metformin doses are different.
What is the nurse's priority action?
-Request medication from the pharmacy
-Administer medication as prescribed
-Contact the HCP for clarification
-Add the new prescription to the medication administration record (MAR)
Contact the HCP for clarification
The client's spouse inquires about the client's blood sugar because she has never seen
it that high, and she reports that the client isn't even eating. What is the nurse's best
response?
-I have sen higher. Do not worry
-There are other things to worry about
-Stress can increase blood sugars
-The healthcare provider will discuss it with you
Stress can increase blood sugars
After reviewing the client's assessment data, what is the nurse's priority action?
-Reassure the client's spouse that these results are expected
-Administer lispro insulin SQ as prescribed
Sepsis
the nurse is aware that the older adult client is at an increased risk for surgical
complications due to normal physiological functions and comobidities. Which risk factors
place the older adult client at increased risk for surgical complications?
-Decreased respiratory muscle strength
-Increased glomerular filtration rate
-Enhanced elasticity of the arterial walls
-Rigidity of the arterial walls increases the clients risk for complications
Decreased respiratory muscle strength
Upon completing the clients assessment, the nurse determines that the client has which
surgical risk factors? (select all that apply)
-Metoprolol
-Poor appetite
-Diabetes Mellitus
-Albumin 3.0 g/dL
-Marital status
Metoprolol
Poor appetite
Diabetes Mellitus
Albumin 3.0 g/dL
What is the priority preoperative nursing action to prevent postoperative atelectasis?
-Administer pain medication as needed
-Instruct on incentive spirometer use
-Obtain baseline pulse saturation
-Turn and position every 2 hours
Instruct on incentive spirometer use
Which is the likely reason for the elevated serum creatinine in the absence of kidney
disease?
-Anemia
-Hypertension
-Increased pain
-Dehydration
Dehydration
The nurse is caring for the client who has just been extubated. What should the nurse
do first, after the client is extubated?
-Administer supplemental oxygen
-Auscultate bilateral lung sounds
, -Encourage cough and deep breathing
-Notify the spouse of extubation
Administer supplemental oxygen
One hour has passed since the client was extubated. Which nursing actions take priority
at this time? (select all that apply)
-Monitor respiratory rate
-Assess cardiac rhythm
-Measure blood pressure
-Compare bilateral pulses
-Instruct on mouth care
Monitor respiratory rate
Assess cardiac rhythm
Based on the nurse's assessment, which is the priority nursing action?
-Give acetaminophen
-Administer morphine
-Monitor urine output
-Assess mental status
Administer morphine
Based on the healthcare provider's (HCP) prescription, the pharmacy dispenses
morphine 4mg per 1mL. How many mL should the nurse administer to the client?
(numerical value only. If required, round to nearest hundredth)
0.25
Upon reviewing the remaining postoperative prescriptions and comparing with
preoperative prescriptions, the nurse realizes that the metformin doses are different.
What is the nurse's priority action?
-Request medication from the pharmacy
-Administer medication as prescribed
-Contact the HCP for clarification
-Add the new prescription to the medication administration record (MAR)
Contact the HCP for clarification
The client's spouse inquires about the client's blood sugar because she has never seen
it that high, and she reports that the client isn't even eating. What is the nurse's best
response?
-I have sen higher. Do not worry
-There are other things to worry about
-Stress can increase blood sugars
-The healthcare provider will discuss it with you
Stress can increase blood sugars
After reviewing the client's assessment data, what is the nurse's priority action?
-Reassure the client's spouse that these results are expected
-Administer lispro insulin SQ as prescribed
