FUNDAMENTALS EXIT HESI
QUESTIONS AND ANSWERS 100%
CORRECT, TEST BANK 2023
Post surgery, monitor for thrombophlebitis especially in clients who were in the ______ position
during surgery (Correct Answers) lithotomy
Post surgery, maintain NPO status until (Correct Answers) gag reflex and peristalsis has returned
If the client does not have a urinary catheter, the client is expected to void within ____________
(Correct Answers) 6-8 H postoperatively depending on the type of anesthesia delivered; ensure
that the amount is at least 200 mL
Assessment of postoperative pneumonia (Correct Answers) Dyspnea, increased RR, crackles
over involved lung area, elevated temp, productive cough and chest pain
If the client had spinal anesthesia.... (Correct Answers) do not elevate the legs any higher than
placing them on the pillow; other wise, the diaphragm muscles needed for effective breathing
could be impaired
Prevention of thrombophlebitis (Correct Answers) 1. Elevate extremity 30 degrees without
allowing any pressure on the popliteal area
2. Encourage the use of anti embolism stockings as prescribed; remove stockings twice a dat to
wash and inspect the legs
3. Use a sequential compression device
4. Perform passive range of motion exercises every 2 H if the client is confined to bed rest
5. Encourage early ambulation as prescribed
6. Do not allow the client to dangle their legs
8. Instruct the client not to sit in 1 position for an extended period of time
9. Administer anticoagulants such as heparin, sodium, or enoxaparin, as prescribed
Urinary retention (Correct Answers) involuntary accumulation of urine in the bladder as a result
of loss of muscle tone. It is cause by the effects of anesthetics or opioid analgesics and appears 6-
8 H after surgery
Paralytic ileus (Correct Answers) failure of the appropriate forward movement of bowel contents
that may occur as a result of anesthetic medications or of manipulation of the bowel during the
surgical procedure.
, S/S: vomiting postoperatively, abdominal distention, absence of bowel sounds, bowel movement,
or flatus
Wound infection (Correct Answers) Usually occurs 3-6 days after surgery and in clients with
existing conditions such as DM or immunocompromised.
Wound dehiscence (Correct Answers) separation of the wound edges at the suture line; it usually
occurs 6-8 days after surgery
Wound evisceration (Correct Answers) protrusion of the internal organs through an incision; it
usually occurs 6-8 days after surgery. It is most common among obese clients, clients who have
had abdominal surgery, or those who have poor wound-healing ability. It is a MEDICAL
EMERGENCY
Priority nursing actions for wound evisceration (Correct Answers) 1. call for help (surgeon and
supplies)
2. stay with client (surgeon/supplies come to you)
3. while waiting for help, place in low fowler's with knees bent to prevent abdominal tension on
suture
4.instruct client to remain quiet and not cough
5.cover wound with sterile normal saline dressing and keep dressing moist
6. take vitals and monitor for shock
7. prepare for surgery as necessary
8. document
The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is
the most appropriate datum to use in planning administration of intravenous fluids to this client?
(Correct Answers) The number of milliliters in the previous hour's urine output
The nurse notes the presence of U waves on a client's cardiac monitor screen. What actions
should the nurse take? (Correct Answers)
Carbon monoxide levels between 11% and 20% (Correct Answers) flushing, HA, decreased
visual acuity, decreased cerebral functioning, slight breathlessness
Carbon monoxide levels 21%-40% (Correct Answers) nausea, vomiting, dizziness, tinnitus,
vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia
Carbon monoxide levels 41%-60% (Correct Answers) seizure and coma
Carbon monoxide levels >60% (Correct Answers) results in death
How long should suctioning be limiting to? (Correct Answers) limit the suctioning pass to 10
seconds. Hypoxemia can be caused by prolonged suctioning, which stimulates pacemaker cells
in the heart. A vasovagal response may occur, causing bradycardia
QUESTIONS AND ANSWERS 100%
CORRECT, TEST BANK 2023
Post surgery, monitor for thrombophlebitis especially in clients who were in the ______ position
during surgery (Correct Answers) lithotomy
Post surgery, maintain NPO status until (Correct Answers) gag reflex and peristalsis has returned
If the client does not have a urinary catheter, the client is expected to void within ____________
(Correct Answers) 6-8 H postoperatively depending on the type of anesthesia delivered; ensure
that the amount is at least 200 mL
Assessment of postoperative pneumonia (Correct Answers) Dyspnea, increased RR, crackles
over involved lung area, elevated temp, productive cough and chest pain
If the client had spinal anesthesia.... (Correct Answers) do not elevate the legs any higher than
placing them on the pillow; other wise, the diaphragm muscles needed for effective breathing
could be impaired
Prevention of thrombophlebitis (Correct Answers) 1. Elevate extremity 30 degrees without
allowing any pressure on the popliteal area
2. Encourage the use of anti embolism stockings as prescribed; remove stockings twice a dat to
wash and inspect the legs
3. Use a sequential compression device
4. Perform passive range of motion exercises every 2 H if the client is confined to bed rest
5. Encourage early ambulation as prescribed
6. Do not allow the client to dangle their legs
8. Instruct the client not to sit in 1 position for an extended period of time
9. Administer anticoagulants such as heparin, sodium, or enoxaparin, as prescribed
Urinary retention (Correct Answers) involuntary accumulation of urine in the bladder as a result
of loss of muscle tone. It is cause by the effects of anesthetics or opioid analgesics and appears 6-
8 H after surgery
Paralytic ileus (Correct Answers) failure of the appropriate forward movement of bowel contents
that may occur as a result of anesthetic medications or of manipulation of the bowel during the
surgical procedure.
, S/S: vomiting postoperatively, abdominal distention, absence of bowel sounds, bowel movement,
or flatus
Wound infection (Correct Answers) Usually occurs 3-6 days after surgery and in clients with
existing conditions such as DM or immunocompromised.
Wound dehiscence (Correct Answers) separation of the wound edges at the suture line; it usually
occurs 6-8 days after surgery
Wound evisceration (Correct Answers) protrusion of the internal organs through an incision; it
usually occurs 6-8 days after surgery. It is most common among obese clients, clients who have
had abdominal surgery, or those who have poor wound-healing ability. It is a MEDICAL
EMERGENCY
Priority nursing actions for wound evisceration (Correct Answers) 1. call for help (surgeon and
supplies)
2. stay with client (surgeon/supplies come to you)
3. while waiting for help, place in low fowler's with knees bent to prevent abdominal tension on
suture
4.instruct client to remain quiet and not cough
5.cover wound with sterile normal saline dressing and keep dressing moist
6. take vitals and monitor for shock
7. prepare for surgery as necessary
8. document
The nurse is caring for a client immediately after nephrectomy and renal transplantation. What is
the most appropriate datum to use in planning administration of intravenous fluids to this client?
(Correct Answers) The number of milliliters in the previous hour's urine output
The nurse notes the presence of U waves on a client's cardiac monitor screen. What actions
should the nurse take? (Correct Answers)
Carbon monoxide levels between 11% and 20% (Correct Answers) flushing, HA, decreased
visual acuity, decreased cerebral functioning, slight breathlessness
Carbon monoxide levels 21%-40% (Correct Answers) nausea, vomiting, dizziness, tinnitus,
vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia
Carbon monoxide levels 41%-60% (Correct Answers) seizure and coma
Carbon monoxide levels >60% (Correct Answers) results in death
How long should suctioning be limiting to? (Correct Answers) limit the suctioning pass to 10
seconds. Hypoxemia can be caused by prolonged suctioning, which stimulates pacemaker cells
in the heart. A vasovagal response may occur, causing bradycardia
