HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
1. The nurse reviews the client's med- BP of 160/88 mmHg.
ications. The client indicates that
she has been taking two med- This blood pressure is elevated and requires further
ications; hydrochlorothiazide, a di- action by the nurse.
uretic, and warfarin , an anticoag-
ulant, every day for more than a
year.
Which vital sign requires follow-up
by the nurse?
BP of 160/88 mmHg.
Pulse of 68 beats/min.
Respirations of 14 breaths/min.
Temperature of 97.2° F (36.2° C).
2. What nursing action is most impor- Explain the need to withhold the warfarin prior to
tant? surgery.
Observe the appearance of the Anticoagulants increase the risk for bleeding during
client's oral mucosa. surgery and the postoperative period, so the nurse
Assess the client for any signs of must explain the need to withhold the warfarin prior to
excessive bruising. surgery and instruct the client to contact the surgeon
Review common side effects of to determine how long before surgery the medication
each of the medications. should be stopped.
Explain the need to withhold the
warfarin prior to surgery.
3. Which serum lab value requires fol- WBC of 14,000/μL (4.0 x 109/L).
low-up by the nurse?
The normal WBC count is 4,000 to 10,000/μL (4.0-10
Sodium of 135 mEq/L (135 x 109/L). An increase may indicate the onset of an
mmol/L). infection, which may be a contraindication to surgery.
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
WBC of 14,000/μL (4.0 x 109/L). The nurse should notify the surgeon of this abnormal
Creatinine of 0.7 mg/dl (61.9 lab value.
mmol/L).
Hemoglobin of 14 g/dL (140 g/L).
4. Preoperative Teaching Demonstrate the deep breathing and coughing tech-
The nurse talks with the client nique again.
about what to expect the day
of surgery and during the im- The client has demonstrated incorrect technique. When
mediate postoperative period. The performing deep breathing exercises, the client should
nurse provides instructions re- inhale through the nose and exhale slowly through
garding cough and deep breath- the mouth without pursing the lips. The nurse should
ing exercises. The client performs demonstrate the entire procedure again for best learn-
a return demonstration by breath- ing by the client.
ing in deeply through their mouth
and exhaling forcefully and rapidly
through pursed lips.
What action should the nurse im-
plement?
Advise the client to avoid pursing
her lips when exhaling.
Remind the client to cough after
taking 2 to 3 breaths.
Demonstrate the deep breathing
and coughing technique again.
Document successful completion
of the return demonstration.
5. When the nurse begins teaching "Bedsores are one of many problems that can occur
about the benefits of early mo- from prolonged bedrest."
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
bilization following surgery, the This response acknowledges the client's previous
client states, "Oh, I know if I stay in learning and promotes further learning related to other
bed very long I will get bedsores." complications of immobility such as thrombus forma-
tion, constipation, and atelectasis.
How should the nurse respond?
"Getting a bedsore is very serious.
Sometimes people die from infect-
ed bedsores."
"The nurses will make sure you do
not stay in bed long enough to get
bedsores."
"Bedsores are one of many prob-
lems that can occur from pro-
longed bedrest."
"Those are now called pressure ul-
cers because they are caused by
pressure."
6. The nurse discusses postopera- The pump has a control device that prevents you from
tive pain management with the taking too much medicine."
client and explains the use of a
patient-controlled analgesia (PCA) This response provides the client with the information
pump. The client expresses fear needed to understand that she cannot overdose herself
that they might accidentally over- while she is sedated after surgery.
dose herself, since they will be
sleepy after surgery.
How should the nurse respond?
"You will only use the PCA pump for
the first 24 hours after surgery."
"The surgeon will prescribe the
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
dose of medication that is correct
for you."
"I will tell the surgeon that you pre-
fer that the nurses administer your
pain medicine."
"The pump has a control device
that prevents you from taking too
much medicine."
7. Therapeutic Communication Quietly sit with the client.
While discussing postoperative
pain management strategies with Offering one's presence is a caring and therapeutic
the client, the nurse observes them response.
begin to cry.
What action should the nurse
take?
Quietly sit with the client.
Offer reassurance about the
surgery.
Calmly continue the preoperative
instructions.
Leave the room until the client has
composed herself.
8. After the client stops crying, she "It sounds as if you went through a difficult time when
states, "My father was in so much your father died."
pain before he died. Talking about
pain brings back so many memo- This open-ended acknowledgment of the client's dis-
ries." tress is therapeutic and allows the opportunity for fur-
ther discussion by the client if desired.
How should the nurse respond?
Study online at https://quizlet.com/_dka0me
1. The nurse reviews the client's med- BP of 160/88 mmHg.
ications. The client indicates that
she has been taking two med- This blood pressure is elevated and requires further
ications; hydrochlorothiazide, a di- action by the nurse.
uretic, and warfarin , an anticoag-
ulant, every day for more than a
year.
Which vital sign requires follow-up
by the nurse?
BP of 160/88 mmHg.
Pulse of 68 beats/min.
Respirations of 14 breaths/min.
Temperature of 97.2° F (36.2° C).
2. What nursing action is most impor- Explain the need to withhold the warfarin prior to
tant? surgery.
Observe the appearance of the Anticoagulants increase the risk for bleeding during
client's oral mucosa. surgery and the postoperative period, so the nurse
Assess the client for any signs of must explain the need to withhold the warfarin prior to
excessive bruising. surgery and instruct the client to contact the surgeon
Review common side effects of to determine how long before surgery the medication
each of the medications. should be stopped.
Explain the need to withhold the
warfarin prior to surgery.
3. Which serum lab value requires fol- WBC of 14,000/μL (4.0 x 109/L).
low-up by the nurse?
The normal WBC count is 4,000 to 10,000/μL (4.0-10
Sodium of 135 mEq/L (135 x 109/L). An increase may indicate the onset of an
mmol/L). infection, which may be a contraindication to surgery.
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
WBC of 14,000/μL (4.0 x 109/L). The nurse should notify the surgeon of this abnormal
Creatinine of 0.7 mg/dl (61.9 lab value.
mmol/L).
Hemoglobin of 14 g/dL (140 g/L).
4. Preoperative Teaching Demonstrate the deep breathing and coughing tech-
The nurse talks with the client nique again.
about what to expect the day
of surgery and during the im- The client has demonstrated incorrect technique. When
mediate postoperative period. The performing deep breathing exercises, the client should
nurse provides instructions re- inhale through the nose and exhale slowly through
garding cough and deep breath- the mouth without pursing the lips. The nurse should
ing exercises. The client performs demonstrate the entire procedure again for best learn-
a return demonstration by breath- ing by the client.
ing in deeply through their mouth
and exhaling forcefully and rapidly
through pursed lips.
What action should the nurse im-
plement?
Advise the client to avoid pursing
her lips when exhaling.
Remind the client to cough after
taking 2 to 3 breaths.
Demonstrate the deep breathing
and coughing technique again.
Document successful completion
of the return demonstration.
5. When the nurse begins teaching "Bedsores are one of many problems that can occur
about the benefits of early mo- from prolonged bedrest."
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
bilization following surgery, the This response acknowledges the client's previous
client states, "Oh, I know if I stay in learning and promotes further learning related to other
bed very long I will get bedsores." complications of immobility such as thrombus forma-
tion, constipation, and atelectasis.
How should the nurse respond?
"Getting a bedsore is very serious.
Sometimes people die from infect-
ed bedsores."
"The nurses will make sure you do
not stay in bed long enough to get
bedsores."
"Bedsores are one of many prob-
lems that can occur from pro-
longed bedrest."
"Those are now called pressure ul-
cers because they are caused by
pressure."
6. The nurse discusses postopera- The pump has a control device that prevents you from
tive pain management with the taking too much medicine."
client and explains the use of a
patient-controlled analgesia (PCA) This response provides the client with the information
pump. The client expresses fear needed to understand that she cannot overdose herself
that they might accidentally over- while she is sedated after surgery.
dose herself, since they will be
sleepy after surgery.
How should the nurse respond?
"You will only use the PCA pump for
the first 24 hours after surgery."
"The surgeon will prescribe the
, HESI Case Studies Fall 2023
Study online at https://quizlet.com/_dka0me
dose of medication that is correct
for you."
"I will tell the surgeon that you pre-
fer that the nurses administer your
pain medicine."
"The pump has a control device
that prevents you from taking too
much medicine."
7. Therapeutic Communication Quietly sit with the client.
While discussing postoperative
pain management strategies with Offering one's presence is a caring and therapeutic
the client, the nurse observes them response.
begin to cry.
What action should the nurse
take?
Quietly sit with the client.
Offer reassurance about the
surgery.
Calmly continue the preoperative
instructions.
Leave the room until the client has
composed herself.
8. After the client stops crying, she "It sounds as if you went through a difficult time when
states, "My father was in so much your father died."
pain before he died. Talking about
pain brings back so many memo- This open-ended acknowledgment of the client's dis-
ries." tress is therapeutic and allows the opportunity for fur-
ther discussion by the client if desired.
How should the nurse respond?
