HESI CASE STUDY: ADVANCED
CARDIAC LIFE SUPPORT (ACLS);
SEPSIS WITH COMPLETE SOLUTION
100% CORRECT RATED A+
1. Geriatric Surgical Risks
Older adults face higher perioperative risks due to age-related decline in organ
reserve.
Key Risk Factor: Reduced respiratory muscle strength. This makes it
harder for the patient to cough effectively or take deep breaths post-surgery,
significantly increasing the risk of pneumonia and respiratory failure.
Other factors: Reduced cardiac output, decreased glomerular filtration rate
(GFR), and thinner skin.
2. Identifying Patient-Specific Risk Factors
When assessing a surgical candidate, certain clinical findings serve as "red flags"
that require intervention:
Medications: Metoprolol (Beta-blockers can affect heart rate and blood
pressure response to anesthesia and stress).
Nutritional Status: Poor appetite and a low Albumin level (3.0 g/dL)
indicate malnutrition, which severely impairs wound healing and increases
infection risk.
Chronic Disease: Diabetes Mellitus increases the risk of fluctuating blood
sugar levels and delayed healing.
3. Preventing Postoperative Respiratory Complications
The goal is to keep the alveoli open and prevent them from collapsing (atelectasis)
while the patient is less mobile.
Priority Nursing Action: Instruction on the Incentive Spirometer (IS).
, Rationale: Teaching this before surgery is essential because the patient will
be more alert and less in pain than they will be immediately after the
procedure. Using the IS encourages deep, sustained inspiration.
4. Interpreting Renal Labs
While elevated creatinine is often a marker of chronic kidney disease, it can also
reflect acute fluid status.
Common Non-Renal Cause: Dehydration. In a preoperative patient who
has been NPO (nothing by mouth), a lack of fluid volume results in
concentrated blood and reduced renal perfusion, which can cause the serum
creatinine to rise temporarily even if the kidneys themselves are healthy.
5. The nurse is caring for the client who has just been extubated. What should the
nurse do first, after the client is extubated? -ANSWER ✔✔Administer
supplemental oxygen.
6. One hour has passed since the client was extubated. Which nursing actions take
priority at this time? (Select all that apply.) -ANSWER ✔✔Monitor respiratory
rate.
Assess cardiac rhythm.
7. Based on the nurse's assessment, which is the priority nursing action? -
ANSWER ✔✔Administer morphine.
8. Based on the healthcare provider's (HCP) prescription, the pharmacy dispenses
morphine 4 mg per 1 mL. How many mL should the nurse administer to the client?
(Enter numerical value only. If rounding is required, round to the nearest
hundredth.) -ANSWER ✔✔0.25
CARDIAC LIFE SUPPORT (ACLS);
SEPSIS WITH COMPLETE SOLUTION
100% CORRECT RATED A+
1. Geriatric Surgical Risks
Older adults face higher perioperative risks due to age-related decline in organ
reserve.
Key Risk Factor: Reduced respiratory muscle strength. This makes it
harder for the patient to cough effectively or take deep breaths post-surgery,
significantly increasing the risk of pneumonia and respiratory failure.
Other factors: Reduced cardiac output, decreased glomerular filtration rate
(GFR), and thinner skin.
2. Identifying Patient-Specific Risk Factors
When assessing a surgical candidate, certain clinical findings serve as "red flags"
that require intervention:
Medications: Metoprolol (Beta-blockers can affect heart rate and blood
pressure response to anesthesia and stress).
Nutritional Status: Poor appetite and a low Albumin level (3.0 g/dL)
indicate malnutrition, which severely impairs wound healing and increases
infection risk.
Chronic Disease: Diabetes Mellitus increases the risk of fluctuating blood
sugar levels and delayed healing.
3. Preventing Postoperative Respiratory Complications
The goal is to keep the alveoli open and prevent them from collapsing (atelectasis)
while the patient is less mobile.
Priority Nursing Action: Instruction on the Incentive Spirometer (IS).
, Rationale: Teaching this before surgery is essential because the patient will
be more alert and less in pain than they will be immediately after the
procedure. Using the IS encourages deep, sustained inspiration.
4. Interpreting Renal Labs
While elevated creatinine is often a marker of chronic kidney disease, it can also
reflect acute fluid status.
Common Non-Renal Cause: Dehydration. In a preoperative patient who
has been NPO (nothing by mouth), a lack of fluid volume results in
concentrated blood and reduced renal perfusion, which can cause the serum
creatinine to rise temporarily even if the kidneys themselves are healthy.
5. The nurse is caring for the client who has just been extubated. What should the
nurse do first, after the client is extubated? -ANSWER ✔✔Administer
supplemental oxygen.
6. One hour has passed since the client was extubated. Which nursing actions take
priority at this time? (Select all that apply.) -ANSWER ✔✔Monitor respiratory
rate.
Assess cardiac rhythm.
7. Based on the nurse's assessment, which is the priority nursing action? -
ANSWER ✔✔Administer morphine.
8. Based on the healthcare provider's (HCP) prescription, the pharmacy dispenses
morphine 4 mg per 1 mL. How many mL should the nurse administer to the client?
(Enter numerical value only. If rounding is required, round to the nearest
hundredth.) -ANSWER ✔✔0.25
