HESI Case Studies Fall 2024 study set- 447
Questions & Answers latest update 2024-25
The nurse should ensure that the markings on the hips are correct to help reduce the potential
for error during surgery. When the surgical site involves a distinction between left and right
sides of the body, marking the site is a required component of The Joint Commission's universal
protocol to prevent wrong site, wrong procedure, wrong person surgery.
Intraoperative Care
The client is transferred to a stretcher and taken to the operating room (OR). The nurse assists
the client off the stretcher and onto the OR table. After general anesthesia is induced, the nurse
positions the client for surgery.
Which nursing diagnosis has the highest priority at this time?
Ineffective protection.
Ineffective tissue perfusion.
Risk for perioperative-positioning injury.
Risk for imbalanced body temperature. - ✔✔Risk for perioperative-positioning injury.
During surgery the client may remain in one position for a prolonged period. The nurse must
ensure that the client is protected from injury secondary to inappropriate positioning.
Once the OR team has assembled in the room, the circulating nurse calls for a time out.
What action should the nurse take during the time out?
Ensure that sufficient surgical supplies are available.
,Check that all surgical personnel are properly attired.
Review the scheduled procedure, site, and client.
Confirm that informed consent has been obtained. - ✔✔Review the scheduled procedure,
site, and client.
A time out, the designated method for final verification before surgery begins, is a component
of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong
person surgery.
Immediate Postoperative Care
The surgery is successfully completed without complications.Following surgery, the client is
admitted to the Post Anesthesia Care Unit. The operative report indicates that the client had a
left hip replacement under general anesthesia. The initial nursing assessment reveals that the
client is not responding to verbal stimuli. Their vital signs are T 97.6° F (36.4° C), P 88, R 14, and
BP 130/70.
What action should the nurse implement first?
Position the client on her side.
Observe the surgical dressing.
Place the call bell within reach.
Remove the oral airway. - ✔✔Position the client on her side.
During the immediate postanesthesia period, the unconscious client should be positioned on
the side to maintain an open airway and promote drainage of secretions.
While assessing the client, the nurse observes that the surgical dressing is in place on the left
hip, with no visible drainage.
How should the nurse document this finding?
,No problems with dressing on left hip.
Left hip dressing clean, dry, and intact.
Dressing present over left hip incision.
Incision well-approximated with no drainage. - ✔✔Left hip dressing clean, dry, and intact.
This documentation is concise but thorough, providing a clear picture of the assessed data.
Pharmacologic Calculations
When the client arrives on the unit, the nurse notes that their IV is wide open. Review of the
client's postoperative prescriptions indicates that sodium chloride 0.9% is to infuse at 75
mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour. An infusion pump is not
immediately available, so the nurse notes that the infusion tubing has a drop factor of 15
drops/mL and resets the IV.
At what rate in drops/min, should the IV infuse? (Enter numeric value only. If rounding is
required, round to the whole number.) - ✔✔19
While the nurse begins to assess the client, another nurse finds an infusion pump and prepares
a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of
cefazolin, which arrives from the pharmacy diluted in 50 mL of sodium chloride 9% and is to be
administered over 30 minutes.
At what rate in mL/hr, should the infusion pump be set? (Enter numeric value only. If rounding
is required, round to the whole number.) - ✔✔100
What action should the nurse take to assess for atelectasis?
Auscultate the client's breath sounds.
Observe the appearance of the sputum.
, Determine the client's temperature.
Measure the client's blood pressure. - ✔✔Auscultate the client's breath sounds.
Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with
changes in breathing patterns, are expected findings when atelectasis occurs.
The nurse determines that the client's bowel sounds are hypoactive.
What action should the nurse implement in response to this finding?
Document the assessment finding in the chart.
Notify the surgeon of the assessment finding.
Review the client's serum electrolyte values.
Administer a laxative prescribed for PRN use. - ✔✔Document the assessment finding in the
chart.
Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse
should document this finding in the chart and continue to monitor the client.
Postoperative Wound Management
During the postoperative assessment, the nurse observes the client's surgical site. The left hip
dressing has a moderate amount of sanguineous drainage.
What action(s) should the nurse implement? (Select all that apply. One, some, or all options
may be correct.)
Apply pressure to the site.
Elevate the leg on a pillow.
Observe the linens under the hip.
Use sterile technique to replace the dressing.
Questions & Answers latest update 2024-25
The nurse should ensure that the markings on the hips are correct to help reduce the potential
for error during surgery. When the surgical site involves a distinction between left and right
sides of the body, marking the site is a required component of The Joint Commission's universal
protocol to prevent wrong site, wrong procedure, wrong person surgery.
Intraoperative Care
The client is transferred to a stretcher and taken to the operating room (OR). The nurse assists
the client off the stretcher and onto the OR table. After general anesthesia is induced, the nurse
positions the client for surgery.
Which nursing diagnosis has the highest priority at this time?
Ineffective protection.
Ineffective tissue perfusion.
Risk for perioperative-positioning injury.
Risk for imbalanced body temperature. - ✔✔Risk for perioperative-positioning injury.
During surgery the client may remain in one position for a prolonged period. The nurse must
ensure that the client is protected from injury secondary to inappropriate positioning.
Once the OR team has assembled in the room, the circulating nurse calls for a time out.
What action should the nurse take during the time out?
Ensure that sufficient surgical supplies are available.
,Check that all surgical personnel are properly attired.
Review the scheduled procedure, site, and client.
Confirm that informed consent has been obtained. - ✔✔Review the scheduled procedure,
site, and client.
A time out, the designated method for final verification before surgery begins, is a component
of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong
person surgery.
Immediate Postoperative Care
The surgery is successfully completed without complications.Following surgery, the client is
admitted to the Post Anesthesia Care Unit. The operative report indicates that the client had a
left hip replacement under general anesthesia. The initial nursing assessment reveals that the
client is not responding to verbal stimuli. Their vital signs are T 97.6° F (36.4° C), P 88, R 14, and
BP 130/70.
What action should the nurse implement first?
Position the client on her side.
Observe the surgical dressing.
Place the call bell within reach.
Remove the oral airway. - ✔✔Position the client on her side.
During the immediate postanesthesia period, the unconscious client should be positioned on
the side to maintain an open airway and promote drainage of secretions.
While assessing the client, the nurse observes that the surgical dressing is in place on the left
hip, with no visible drainage.
How should the nurse document this finding?
,No problems with dressing on left hip.
Left hip dressing clean, dry, and intact.
Dressing present over left hip incision.
Incision well-approximated with no drainage. - ✔✔Left hip dressing clean, dry, and intact.
This documentation is concise but thorough, providing a clear picture of the assessed data.
Pharmacologic Calculations
When the client arrives on the unit, the nurse notes that their IV is wide open. Review of the
client's postoperative prescriptions indicates that sodium chloride 0.9% is to infuse at 75
mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour. An infusion pump is not
immediately available, so the nurse notes that the infusion tubing has a drop factor of 15
drops/mL and resets the IV.
At what rate in drops/min, should the IV infuse? (Enter numeric value only. If rounding is
required, round to the whole number.) - ✔✔19
While the nurse begins to assess the client, another nurse finds an infusion pump and prepares
a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of
cefazolin, which arrives from the pharmacy diluted in 50 mL of sodium chloride 9% and is to be
administered over 30 minutes.
At what rate in mL/hr, should the infusion pump be set? (Enter numeric value only. If rounding
is required, round to the whole number.) - ✔✔100
What action should the nurse take to assess for atelectasis?
Auscultate the client's breath sounds.
Observe the appearance of the sputum.
, Determine the client's temperature.
Measure the client's blood pressure. - ✔✔Auscultate the client's breath sounds.
Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with
changes in breathing patterns, are expected findings when atelectasis occurs.
The nurse determines that the client's bowel sounds are hypoactive.
What action should the nurse implement in response to this finding?
Document the assessment finding in the chart.
Notify the surgeon of the assessment finding.
Review the client's serum electrolyte values.
Administer a laxative prescribed for PRN use. - ✔✔Document the assessment finding in the
chart.
Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse
should document this finding in the chart and continue to monitor the client.
Postoperative Wound Management
During the postoperative assessment, the nurse observes the client's surgical site. The left hip
dressing has a moderate amount of sanguineous drainage.
What action(s) should the nurse implement? (Select all that apply. One, some, or all options
may be correct.)
Apply pressure to the site.
Elevate the leg on a pillow.
Observe the linens under the hip.
Use sterile technique to replace the dressing.
