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HESI Case Studies Fall Exam Questions And Answers (Guaranteed A+)

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©FYNDLAY EXAM SOLUTIONS 2024/2025 ALL RIGHTS RESERVED. 1 | P a g e HESI Case Studies Fall Exam Questions And Answers (Guaranteed A+) The nurse reviews the client's medications. The client indicates that she has been taking two medications; hydrochlorothiazide, a diuretic, and warfarin , an a...

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©FYNDLAY EXAM SOLUTIONS 2024/2025

ALL RIGHTS RESERVED.

HESI Case Studies Fall Exam Questions And
Answers (Guaranteed A+)

The nurse reviews the client's medications. The client indicates that she has been taking two

medications; hydrochlorothiazide, a diuretic, and warfarin , an anticoagulant, every day for

more than a year.

Which vital sign requires follow-up by the nurse?

BP of 160/88 mmHg.

Pulse of 68 beats/min.

Respirations of 14 breaths/min.

Temperature of 97.2° F (36.2° C). - answer✔BP of 160/88 mmHg.

This blood pressure is elevated and requires further action by the nurse.

What nursing action is most important?

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Observe the appearance of the client's oral mucosa.

Assess the client for any signs of excessive bruising.

Review common side effects of each of the medications.

Explain the need to withhold the warfarin prior to surgery. - answer✔Explain the need to

withhold the warfarin prior to surgery.

Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so

the nurse must explain the need to withhold the warfarin prior to surgery and instruct the

client to contact the surgeon to determine how long before surgery the medication should be

stopped.

Which serum lab value requires follow-up by the nurse?

Sodium of 135 mEq/L (135 mmol/L).

WBC of 14,000/μL (4.0 x 109/L).

Creatinine of 0.7 mg/dl (61.9 mmol/L).

Hemoglobin of 14 g/dL (140 g/L). - answer✔WBC of 14,000/μL (4.0 x 109/L).

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The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the

onset of an infection, which may be a contraindication to surgery. The nurse should notify the

surgeon of this abnormal lab value.

Preoperative Teaching

The nurse talks with the client about what to expect the day of surgery and during the

immediate postoperative period. The nurse provides instructions regarding cough and deep

breathing exercises. The client performs a return demonstration by breathing in deeply through

their mouth and exhaling forcefully and rapidly through pursed lips.

What action should the nurse implement?

Advise the client to avoid pursing her lips when exhaling.

Remind the client to cough after taking 2 to 3 breaths.

Demonstrate the deep breathing and coughing technique again.

Document successful completion of the return demonstration. - answer✔Demonstrate the

deep breathing and coughing technique again.

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The client has demonstrated incorrect technique. When performing deep breathing exercises,

the client should inhale through the nose and exhale slowly through the mouth without pursing

the lips. The nurse should demonstrate the entire procedure again for best learning by the

client.

When the nurse begins teaching about the benefits of early mobilization following surgery, the

client states, "Oh, I know if I stay in bed very long I will get bedsores."

How should the nurse respond?

"Getting a bedsore is very serious. Sometimes people die from infected bedsores."

"The nurses will make sure you do not stay in bed long enough to get bedsores."

"Bedsores are one of many problems that can occur from prolonged bedrest."

"Those are now called pressure ulcers because they are caused by pressure." -

answer✔"Bedsores are one of many problems that can occur from prolonged bedrest."

This response acknowledges the client's previous learning and promotes further learning

related to other complications of immobility such as thrombus formation, constipation, and

atelectasis.

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