HESI FOCUS ON ADULT HEALTH 100 QUESTIONS,
sS sS sS sS sS sS
ANSWERS AND RATIONALE sS sS sS
.
. A nurse is monitoring a client who is taking spironolactone for the
sS sS sS sS sS sS sS sS sS sS sS
sS treatment of hypertension. Which findings denote adverse effects of the
sS sS sS sS sS sS sS sS sS
sS medication? Selectall that apply. sS S
s sS sS
A. Constipation
B. Tall T waves Correct sS sS sS
C. Hyporeflexia
D. Shallow respirations sS
E. Prolonged PR interval Correct sS sS sS
F. Hyperactive bowel sounds Correct sS sS sS
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
sS sS sS sS sS sS
sS diuretics can cause hyperkalemia. Cardiovascular manifestations of
sS sS sS sS sS sS
sS hyperkalemia include tall T waves, widened QRS complexes, prolonged PR
sS sS sS sS sS sS sS sS sS
sS intervals, and flat P waves. Other cardiovascular manifestations include an
sS sS sS sS sS sS sS sS sS
sS irregular heart rate, decreased blood pressure, and ectopic heartbeats.
sS sS sS sS sS sS sS sS
sS Muscletwitches occur in hyperkalemia. Hyperactive bowel sounds and
sS sS sS sS sS sS sS sS
sS diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow
sS sS sS sS sS sS sS sS
sS respirations aresigns of hypokalemia. sS sS sS sS
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sS sS sS sS sS sS sS sS
sS sparing diuretic will assist you in determining that hyperkalemia is an
sS sS sS sS sS sS sS sS sS sS
sS adverse effect of the medication. Recalling the manifestations of
sS sS sS sS sS sS sS sS
sS hyperkalemia will directyou to the correct options. Also, note that the
sS sS sS sS sS sS sS sS sS sS sS
sS incorrect options are comparable or alike in that they indicate a slowed
sS sS sS sS sS sS sS sS sS sS sS
sS body response or function. Review the adverse effects of spironolactone and
sS sS sS sS sS sS sS sS sS sS
sS the manifestations of hyperkalemia if youhad difficulty with this question.
sS sS sS sS sS sS sS sS sS sS
. Level of Cognitive Ability: Analyzing
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Nursing Process/Assessment
sS sS sS
. Content Area: Adult Pharmacology
sS sS sS
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
sS sS sS sS sS sS
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids
sS sS sS sS sS
andElectrolytes
sS sS
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug
sS sS sS sS sS sS sS sS sS
handbook2015. (pp. 1125-1127) St. Louis: Saunders.
sS sS sS sS sS sS sS
. Awarded 3.0 points out of 3.0 possible points.
sS sS sS sS sS sS sS
. 2.ID: 9477057138
sS
, . A nurse is providing dietary instructions to a client with chronic
sS sS sS sS sS sS sS sS sS sS
sS obstructive pulmonary disease (COPD) who is experiencing a loss of
sS sS sS sS sS sS sS sS sS
sS appetite and complains of feeling “too full to eat.” What does the nurse
sS sS sS sS sS sS sS sS sS sS sS sS
encourage the clientto do? Select all that apply.
sS sS sS sS sS sS sS sS sS
A. Avoid drinking fluids before and during meals Correct
sS sS sS sS sS sS sS
B. Eat a variety of dark-green vegetables, such as broccoli
sS sS sS sS sS sS sS sS
C. Have snacks, such as crackers and cheese, between meals
sS sS sS sS sS sS sS sS
D. Select foods that are easy to chew and are not gas forming Correct
sS sS sS sS sS sS sS sS sS sS sS sS
E. Consume high-calorie drinks, such as milkshakes, between meals
sS sS sS sS sS sS sS
. Rationale: COPD is a progressive and irreversible condition characterized by
sS sS sS sS sS sS sS sS sS
sS diminished inspiratory and expiratory capacity of the lungs. Instruct the
sS sS sS sS sS sS sS sS sS
sS client who complains of feeling too full to eat, to avoid drinking fluids
sS sS sS sS sS sS sS sS sS sS sS sS
sS before and during the meal. Dry foods such as crackers stimulate coughing;
sS sS sS sS sS sS sS sS sS sS sS
sS foods such as milk and chocolate may increase the thickness of saliva and
sS sS sS sS sS sS sS sS sS sS sS sS
secretions. Cheeseis constipating and should also be avoided by the client.
sS sS sS sS sS sS sS sS sS sS sS sS
sS The nurse should also teach the client about foods that are easy to chew
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS and do not encourage the formation of gas; for this reason, broccoli, which
sS sS sS sS sS sS sS sS sS sS sS sS
sS is a gas-forming food, should be avoided.
sS sS sS sS sS sS
. Test-Taking Strategy: Use the process of elimination. Recalling that milk may
sS sS sS sS sS sS sS sS sS sS
sS increase the thickness of saliva will assist you in eliminating the option that
sS sS sS sS sS sS sS sS sS sS sS sS
sS encourages the consumption of milkshakes. Eliminate the option in which
sS sS sS sS sS sS sS sS sS
sS the consumption of broccoli is encouraged, because it is a gas-forming food.
sS sS sS sS sS sS sS sS sS sS sS
sS To select from the remaining options, note the strategic words “too full to
sS sS sS sS sS sS sS sS sS sS sS sS
sS eat” in thequestion and the option that encourages the client to avoid fluids
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS before and during meals; this will direct you to the correct answers. Review
sS sS sS sS sS sS sS sS sS sS sS sS
sS dietary measures for the client with COPD if you had difficulty with this
sS sS sS sS sS sS sS sS sS sS sS sS
sS question.
. Level of Cognitive Ability: Applying
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Teaching and Learning sS sS sS sS
. Content Area: Adult Health/Respiratory
sS sS sS
. Giddens Concepts: Gas Exchange, Nutrition
sS sS sS sS
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
sS sS sS sS sS sS
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
sS sS sS sS sS sS sS sS sS sS
Medical-surgical nursing: Assessment and management of clinical problems (9th sS sS sS sS sS sS sS sS
ed., pp. 595-596). St. Louis: Mosby.
sS sS sS sS sS
. Awarded 2.0 points out of 2.0 possible points.
sS sS sS sS sS sS sS
. 3.ID: 9477057160
sS
. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
sS sS sS sS sS sS sS sS sS sS sS sS sS sS
, infection. Forty-eight hours after administration, the nurse checks the test
sS sS sS sS sS sS sS sS sS
site(see image).
sS sS sS
.
. The nurse documents the result of the test as:
sS sS sS sS sS sS sS sS
A. Positive Correct sS
B. Negative
C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of
sS sS sS sS sS sS sS sS sS sS
sS tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter
sS sS sS sS sS sS sS sS sS sS sS
sS is considered positive in a client with HIV infection. A reaction measuring
sS sS sS sS sS sS sS sS sS sS sS
sS 10 mm or more in diameter is considered positive in a non-
sS sS sS sS sS sS sS sS sS sS sS
immunosuppressed client. In this instance, the area of induration measures 9 sS sS sS sS sS sS sS sS sS sS
mm, indicating a positive reaction. Apositive reaction does not mean that
sS sS sS sS sS sS sS sS sS sS sS sS
sS active disease is present, but it does indicate exposure to TB or the presence
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS of inactive (dormant) disease.
sS sS sS
. Test-Taking Strategy: Use the process of elimination. Eliminate the options
sS sS sS sS sS sS sS sS sS
sS thatare comparable or alike (negative and insignificant). To select from the
sS sS sS sS sS sS sS sS sS sS sS
sS remaining options, note that the client has HIV, which will assist in
sS sS sS sS sS sS sS sS sS sS sS
sS directing youto the correct option. An area of induration is present, so the
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS test results are notindeterminate. Review the tuberculin skin test and the
sS sS sS sS sS sS sS sS sS sS sS
procedure for interpretingthe results if you had difficulty with this question.
sS sS sS sS sS sS sS sS sS sS sS sS
. Level of Cognitive Ability: Analyzing
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Nursing Process/Assessment
sS sS sS
. Content Area: Adult Health/Respiratory
sS sS sS
. Giddens Concepts: Clinical Judgment, Evidence
sS sS sS sS
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-
sS sS sS sS sS
BasedPractice/Evidence sS
, . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
sS sS sS sS sS sS sS sS sS sS
Medical-surgical nursing: Assessment and management of clinical problems (9thsS sS sS sS sS sS sS sS
ed., pp. 494, 530). St. Louis: Mosby.
sS sS sS sS sS sS
. Awarded 1.0 points out of 1.0 possible points.
sS sS sS sS sS sS sS
. 4.ID: 9477067466
sS
. A nurse is interpreting a central venous pressure (CVP) reading from a client
sS sS sS sS sS sS sS sS sS sS sS sS
sS inwhom right ventricular failure has been diagnosed. From this diagnosis,
sS sS sS sS sS sS sS sS sS sS
sS the nurse would expect that the most likely result is a pressure of:
sS sS sS sS sS sS sS sS sS sS sS sS
A. 4 cm H2O
sS sS
B. 8 cm H2O
sS sS
C. 11 cm H2O sS sS
D. 14 cm H2O Correct sS sS sS
. Rationale: CVP measurements are used to monitor blood volume and the
sS sS sS sS sS sS sS sS sS sS
sS adequacy of venous return to the heart. The CVP measures pressures from
sS sS sS sS sS sS sS sS sS sS sS
sS theright atrium or central veins. The normal CVP is 7 to 12 cm H2O. An
sS sS sS sS sS sS sS sS sS sS sS sS sS sS sS
sS increased CVP reading may indicate right ventricular failure. A low CVP
sS sS sS sS sS sS sS sS sS sS
sS reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings
sS sS sS sS sS sS sS sS sS sS sS sS
sS of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.
sS sS sS sS sS sS sS sS sS sS sS sS sS sS sS
. Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the
sS sS sS sS sS sS sS sS sS
sS pathophysiology of right ventricular failure and recalling the normal CVP sS sS sS sS sS sS sS sS sS
readingwill direct you to the correct option. Review the normal CVP reading
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS and the expected findings in right ventricular failure if you had difficulty
sS sS sS sS sS sS sS sS sS sS sS
sS with this question.
sS sS
. Level of Cognitive Ability: Analyzing
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Nursing Process/Assessment sS sS sS
. Content Area: Adult Health/Cardiovascular
sS sS sS
. Giddens Concepts: Clinical Judgment, Perfusion
sS sS sS sS
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting
sS sS sS sS sS
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
sS sS sS sS sS sS sS sS sS sS
Medical-surgical nursing: Assessment and management of clinical problems (9thsS sS sS sS sS sS sS sS
ed., pp. 1608-1609). St. Louis: Mosby.
sS sS sS sS sS
. Awarded 1.0 points out of 1.0 possible points.
sS sS sS sS sS sS sS
. 5.ID: 9477067454
sS
. A nurse is caring for a client who has just undergone thyroidectomy. Which
sS sS sS sS sS sS sS sS sS sS sS sS
sS technique is the bestway for the nurse to assess the surgical site for
sS sS sS sS sS sS sS sS sS sS sS sS
sS bleeding?
A. Asking the client whether the dressing feels wet sS sS sS sS sS sS sS
B. Looking for moisture on the top of the dressing
sS sS sS sS sS sS sS sS
sS sS sS sS sS sS
ANSWERS AND RATIONALE sS sS sS
.
. A nurse is monitoring a client who is taking spironolactone for the
sS sS sS sS sS sS sS sS sS sS sS
sS treatment of hypertension. Which findings denote adverse effects of the
sS sS sS sS sS sS sS sS sS
sS medication? Selectall that apply. sS S
s sS sS
A. Constipation
B. Tall T waves Correct sS sS sS
C. Hyporeflexia
D. Shallow respirations sS
E. Prolonged PR interval Correct sS sS sS
F. Hyperactive bowel sounds Correct sS sS sS
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
sS sS sS sS sS sS
sS diuretics can cause hyperkalemia. Cardiovascular manifestations of
sS sS sS sS sS sS
sS hyperkalemia include tall T waves, widened QRS complexes, prolonged PR
sS sS sS sS sS sS sS sS sS
sS intervals, and flat P waves. Other cardiovascular manifestations include an
sS sS sS sS sS sS sS sS sS
sS irregular heart rate, decreased blood pressure, and ectopic heartbeats.
sS sS sS sS sS sS sS sS
sS Muscletwitches occur in hyperkalemia. Hyperactive bowel sounds and
sS sS sS sS sS sS sS sS
sS diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow
sS sS sS sS sS sS sS sS
sS respirations aresigns of hypokalemia. sS sS sS sS
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sS sS sS sS sS sS sS sS
sS sparing diuretic will assist you in determining that hyperkalemia is an
sS sS sS sS sS sS sS sS sS sS
sS adverse effect of the medication. Recalling the manifestations of
sS sS sS sS sS sS sS sS
sS hyperkalemia will directyou to the correct options. Also, note that the
sS sS sS sS sS sS sS sS sS sS sS
sS incorrect options are comparable or alike in that they indicate a slowed
sS sS sS sS sS sS sS sS sS sS sS
sS body response or function. Review the adverse effects of spironolactone and
sS sS sS sS sS sS sS sS sS sS
sS the manifestations of hyperkalemia if youhad difficulty with this question.
sS sS sS sS sS sS sS sS sS sS
. Level of Cognitive Ability: Analyzing
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Nursing Process/Assessment
sS sS sS
. Content Area: Adult Pharmacology
sS sS sS
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
sS sS sS sS sS sS
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids
sS sS sS sS sS
andElectrolytes
sS sS
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug
sS sS sS sS sS sS sS sS sS
handbook2015. (pp. 1125-1127) St. Louis: Saunders.
sS sS sS sS sS sS sS
. Awarded 3.0 points out of 3.0 possible points.
sS sS sS sS sS sS sS
. 2.ID: 9477057138
sS
, . A nurse is providing dietary instructions to a client with chronic
sS sS sS sS sS sS sS sS sS sS
sS obstructive pulmonary disease (COPD) who is experiencing a loss of
sS sS sS sS sS sS sS sS sS
sS appetite and complains of feeling “too full to eat.” What does the nurse
sS sS sS sS sS sS sS sS sS sS sS sS
encourage the clientto do? Select all that apply.
sS sS sS sS sS sS sS sS sS
A. Avoid drinking fluids before and during meals Correct
sS sS sS sS sS sS sS
B. Eat a variety of dark-green vegetables, such as broccoli
sS sS sS sS sS sS sS sS
C. Have snacks, such as crackers and cheese, between meals
sS sS sS sS sS sS sS sS
D. Select foods that are easy to chew and are not gas forming Correct
sS sS sS sS sS sS sS sS sS sS sS sS
E. Consume high-calorie drinks, such as milkshakes, between meals
sS sS sS sS sS sS sS
. Rationale: COPD is a progressive and irreversible condition characterized by
sS sS sS sS sS sS sS sS sS
sS diminished inspiratory and expiratory capacity of the lungs. Instruct the
sS sS sS sS sS sS sS sS sS
sS client who complains of feeling too full to eat, to avoid drinking fluids
sS sS sS sS sS sS sS sS sS sS sS sS
sS before and during the meal. Dry foods such as crackers stimulate coughing;
sS sS sS sS sS sS sS sS sS sS sS
sS foods such as milk and chocolate may increase the thickness of saliva and
sS sS sS sS sS sS sS sS sS sS sS sS
secretions. Cheeseis constipating and should also be avoided by the client.
sS sS sS sS sS sS sS sS sS sS sS sS
sS The nurse should also teach the client about foods that are easy to chew
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS and do not encourage the formation of gas; for this reason, broccoli, which
sS sS sS sS sS sS sS sS sS sS sS sS
sS is a gas-forming food, should be avoided.
sS sS sS sS sS sS
. Test-Taking Strategy: Use the process of elimination. Recalling that milk may
sS sS sS sS sS sS sS sS sS sS
sS increase the thickness of saliva will assist you in eliminating the option that
sS sS sS sS sS sS sS sS sS sS sS sS
sS encourages the consumption of milkshakes. Eliminate the option in which
sS sS sS sS sS sS sS sS sS
sS the consumption of broccoli is encouraged, because it is a gas-forming food.
sS sS sS sS sS sS sS sS sS sS sS
sS To select from the remaining options, note the strategic words “too full to
sS sS sS sS sS sS sS sS sS sS sS sS
sS eat” in thequestion and the option that encourages the client to avoid fluids
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS before and during meals; this will direct you to the correct answers. Review
sS sS sS sS sS sS sS sS sS sS sS sS
sS dietary measures for the client with COPD if you had difficulty with this
sS sS sS sS sS sS sS sS sS sS sS sS
sS question.
. Level of Cognitive Ability: Applying
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Teaching and Learning sS sS sS sS
. Content Area: Adult Health/Respiratory
sS sS sS
. Giddens Concepts: Gas Exchange, Nutrition
sS sS sS sS
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
sS sS sS sS sS sS
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
sS sS sS sS sS sS sS sS sS sS
Medical-surgical nursing: Assessment and management of clinical problems (9th sS sS sS sS sS sS sS sS
ed., pp. 595-596). St. Louis: Mosby.
sS sS sS sS sS
. Awarded 2.0 points out of 2.0 possible points.
sS sS sS sS sS sS sS
. 3.ID: 9477057160
sS
. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
sS sS sS sS sS sS sS sS sS sS sS sS sS sS
, infection. Forty-eight hours after administration, the nurse checks the test
sS sS sS sS sS sS sS sS sS
site(see image).
sS sS sS
.
. The nurse documents the result of the test as:
sS sS sS sS sS sS sS sS
A. Positive Correct sS
B. Negative
C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of
sS sS sS sS sS sS sS sS sS sS
sS tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter
sS sS sS sS sS sS sS sS sS sS sS
sS is considered positive in a client with HIV infection. A reaction measuring
sS sS sS sS sS sS sS sS sS sS sS
sS 10 mm or more in diameter is considered positive in a non-
sS sS sS sS sS sS sS sS sS sS sS
immunosuppressed client. In this instance, the area of induration measures 9 sS sS sS sS sS sS sS sS sS sS
mm, indicating a positive reaction. Apositive reaction does not mean that
sS sS sS sS sS sS sS sS sS sS sS sS
sS active disease is present, but it does indicate exposure to TB or the presence
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS of inactive (dormant) disease.
sS sS sS
. Test-Taking Strategy: Use the process of elimination. Eliminate the options
sS sS sS sS sS sS sS sS sS
sS thatare comparable or alike (negative and insignificant). To select from the
sS sS sS sS sS sS sS sS sS sS sS
sS remaining options, note that the client has HIV, which will assist in
sS sS sS sS sS sS sS sS sS sS sS
sS directing youto the correct option. An area of induration is present, so the
sS sS sS sS sS sS sS sS sS sS sS sS sS
sS test results are notindeterminate. Review the tuberculin skin test and the
sS sS sS sS sS sS sS sS sS sS sS
procedure for interpretingthe results if you had difficulty with this question.
sS sS sS sS sS sS sS sS sS sS sS sS
. Level of Cognitive Ability: Analyzing
sS sS sS sS
. Client Needs: Physiological Integrity
sS sS sS
. Integrated Process: Nursing Process/Assessment
sS sS sS
. Content Area: Adult Health/Respiratory
sS sS sS
. Giddens Concepts: Clinical Judgment, Evidence
sS sS sS sS
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-
sS sS sS sS sS
BasedPractice/Evidence sS
, . Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
sS sS sS sS sS sS sS sS sS sS
Medical-surgical nursing: Assessment and management of clinical problems (9thsS sS sS sS sS sS sS sS
ed., pp. 494, 530). St. Louis: Mosby.
sS sS sS sS sS sS
. Awarded 1.0 points out of 1.0 possible points.
sS sS sS sS sS sS sS
. 4.ID: 9477067466
sS
. A nurse is interpreting a central venous pressure (CVP) reading from a client
sS sS sS sS sS sS sS sS sS sS sS sS
sS inwhom right ventricular failure has been diagnosed. From this diagnosis,
sS sS sS sS sS sS sS sS sS sS
sS the nurse would expect that the most likely result is a pressure of:
sS sS sS sS sS sS sS sS sS sS sS sS
A. 4 cm H2O
sS sS
B. 8 cm H2O
sS sS
C. 11 cm H2O sS sS
D. 14 cm H2O Correct sS sS sS
. Rationale: CVP measurements are used to monitor blood volume and the
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sS adequacy of venous return to the heart. The CVP measures pressures from
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sS theright atrium or central veins. The normal CVP is 7 to 12 cm H2O. An
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sS increased CVP reading may indicate right ventricular failure. A low CVP
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sS reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings
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sS of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.
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. Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the
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sS pathophysiology of right ventricular failure and recalling the normal CVP sS sS sS sS sS sS sS sS sS
readingwill direct you to the correct option. Review the normal CVP reading
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sS and the expected findings in right ventricular failure if you had difficulty
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sS with this question.
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. Level of Cognitive Ability: Analyzing
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. Client Needs: Physiological Integrity
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. Integrated Process: Nursing Process/Assessment sS sS sS
. Content Area: Adult Health/Cardiovascular
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. Giddens Concepts: Clinical Judgment, Perfusion
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. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting
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. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
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Medical-surgical nursing: Assessment and management of clinical problems (9thsS sS sS sS sS sS sS sS
ed., pp. 1608-1609). St. Louis: Mosby.
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. Awarded 1.0 points out of 1.0 possible points.
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. 5.ID: 9477067454
sS
. A nurse is caring for a client who has just undergone thyroidectomy. Which
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sS technique is the bestway for the nurse to assess the surgical site for
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sS bleeding?
A. Asking the client whether the dressing feels wet sS sS sS sS sS sS sS
B. Looking for moisture on the top of the dressing
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