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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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)
✅ANS- 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
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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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
✅ANS- 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)
✅ANS- 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
