3/29/25, 8:17 Fundamentals exit HESI |
AM
FUNDAMENTALS EXIT HESI EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
Terms in this set (68)
Post surgery, monitor for thrombophlebitis lithotomy
especially in clients who were in the ______
position during surgery
Post surgery, maintain NPO status until gag reflex and peristalsis has returned
If the client does not have a urinary 6-8 H postoperatively depending on the type of anesthesia delivered; ensure that
catheter, the client is expected to void the amount is at least 200 mL
within ____________
Dyspnea, increased RR, crackles over involved lung area, elevated temp,
Assessment of postoperative pneumonia
productive cough and chest pain
do not elevate the legs any higher than placing them on the pillow; other wise, the
If the client had spinal anesthesia....
diaphragm muscles needed for effective breathing could be impaired
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
Prevention of thrombophlebitis
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
involuntary accumulation of urine in the bladder as a result of loss of muscle tone.
Urinary retention It is cause by the effects of anesthetics or opioid analgesics and appears 6-8 H after
surgery
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
Paralytic ileus surgical procedure.
S/S: vomiting postoperatively, abdominal distention, absence of bowel
sounds, bowel movement, or flatus
Usually occurs 3-6 days after surgery and in clients with existing conditions such as
Wound infection
DM or immunocompromised.
separation of the wound edges at the suture line; it usually occurs 6-8 days after
Wound dehiscence
surgery
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
Wound evisceration
abdominal
surgery, or those who have poor wound-healing ability. It is a MEDICAL
EMERGENCY
1/
5
, 3/29/25, 8:17 Fundamentals exit HESI |
AM
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
Priority nursing actions for wound
4. instruct client to remain quiet and not cough
evisceration
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 The number of milliliters in the previous hour's urine output
immediately after nephrectomy and
renal
transplantation. What is the most
appropriate datum to use in planning
administration of intravenous fluids to this
client?
The nurse notes the presence of U waves
on a client's cardiac monitor screen. What
actions should the nurse take?
Carbon monoxide levels between 11% and flushing, HA, decreased visual acuity, decreased cerebral functioning, slight
20% breathlessness
nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-
Carbon monoxide levels 21%-40%
purple skin, and tachycardia
Carbon monoxide levels 41%-60% seizure and coma
Carbon monoxide levels >60% results in death
limit the suctioning pass to 10 seconds. Hypoxemia can be caused by prolonged
How long should suctioning be limiting to? suctioning, which stimulates pacemaker cells in the heart. A vasovagal response
may occur, causing bradycardia
an opportunistic fungal infection that can occur in the client with AIDS. The
infection begins as a respiratory infection and can progress to disseminated
Histoplasmosis
infection. Typical signs and symptoms include fever, dyspnea, cough, and weight
loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as
well.
The nurse is planning a teaching session 2 to 3 pounds (1-1.5 kg)
with a client who has chronic kidney
disease (CKD) about managing the
condition between dialysis treatments. The
nurse should plan to include the instruction
that weight gain between dialysis
treatments should be ideally what value?
A client undergoing hemodialysis begins to Decrease the ultrafiltration rate. Muscle cramps during hemodialysis result from
experience muscle cramping. What is either too rapid removal of water and sodium or neuromuscular hypersensitivity.
the best action by the hemodialysis The nurse corrects this situation by either slowing down the ultrafiltration rate on
nurse in the hemodialyzerf or administering hypertonic or isotonic normal saline.
this situation?
The nurse checks the serum Infrarenal. Serum myoglobin levels increase in crush injuries when large amounts
myoglobin level for a client with a crush of myoglobin and hemoglobin are released from damaged muscle an blood cells.
injury to the right lower leg because the The accumulation may cause acute tubular necrosis, an infrarenal cause of renal
2/
5
AM
FUNDAMENTALS EXIT HESI EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
Terms in this set (68)
Post surgery, monitor for thrombophlebitis lithotomy
especially in clients who were in the ______
position during surgery
Post surgery, maintain NPO status until gag reflex and peristalsis has returned
If the client does not have a urinary 6-8 H postoperatively depending on the type of anesthesia delivered; ensure that
catheter, the client is expected to void the amount is at least 200 mL
within ____________
Dyspnea, increased RR, crackles over involved lung area, elevated temp,
Assessment of postoperative pneumonia
productive cough and chest pain
do not elevate the legs any higher than placing them on the pillow; other wise, the
If the client had spinal anesthesia....
diaphragm muscles needed for effective breathing could be impaired
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
Prevention of thrombophlebitis
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
involuntary accumulation of urine in the bladder as a result of loss of muscle tone.
Urinary retention It is cause by the effects of anesthetics or opioid analgesics and appears 6-8 H after
surgery
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
Paralytic ileus surgical procedure.
S/S: vomiting postoperatively, abdominal distention, absence of bowel
sounds, bowel movement, or flatus
Usually occurs 3-6 days after surgery and in clients with existing conditions such as
Wound infection
DM or immunocompromised.
separation of the wound edges at the suture line; it usually occurs 6-8 days after
Wound dehiscence
surgery
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
Wound evisceration
abdominal
surgery, or those who have poor wound-healing ability. It is a MEDICAL
EMERGENCY
1/
5
, 3/29/25, 8:17 Fundamentals exit HESI |
AM
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
Priority nursing actions for wound
4. instruct client to remain quiet and not cough
evisceration
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 The number of milliliters in the previous hour's urine output
immediately after nephrectomy and
renal
transplantation. What is the most
appropriate datum to use in planning
administration of intravenous fluids to this
client?
The nurse notes the presence of U waves
on a client's cardiac monitor screen. What
actions should the nurse take?
Carbon monoxide levels between 11% and flushing, HA, decreased visual acuity, decreased cerebral functioning, slight
20% breathlessness
nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-
Carbon monoxide levels 21%-40%
purple skin, and tachycardia
Carbon monoxide levels 41%-60% seizure and coma
Carbon monoxide levels >60% results in death
limit the suctioning pass to 10 seconds. Hypoxemia can be caused by prolonged
How long should suctioning be limiting to? suctioning, which stimulates pacemaker cells in the heart. A vasovagal response
may occur, causing bradycardia
an opportunistic fungal infection that can occur in the client with AIDS. The
infection begins as a respiratory infection and can progress to disseminated
Histoplasmosis
infection. Typical signs and symptoms include fever, dyspnea, cough, and weight
loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as
well.
The nurse is planning a teaching session 2 to 3 pounds (1-1.5 kg)
with a client who has chronic kidney
disease (CKD) about managing the
condition between dialysis treatments. The
nurse should plan to include the instruction
that weight gain between dialysis
treatments should be ideally what value?
A client undergoing hemodialysis begins to Decrease the ultrafiltration rate. Muscle cramps during hemodialysis result from
experience muscle cramping. What is either too rapid removal of water and sodium or neuromuscular hypersensitivity.
the best action by the hemodialysis The nurse corrects this situation by either slowing down the ultrafiltration rate on
nurse in the hemodialyzerf or administering hypertonic or isotonic normal saline.
this situation?
The nurse checks the serum Infrarenal. Serum myoglobin levels increase in crush injuries when large amounts
myoglobin level for a client with a crush of myoglobin and hemoglobin are released from damaged muscle an blood cells.
injury to the right lower leg because the The accumulation may cause acute tubular necrosis, an infrarenal cause of renal
2/
5
