HESI CASE STUDY: ADVANCED

HESI CASE STUDY: ADVANCED

CARDIAC LIFE SUPPORT ACLS 2024

QUESTIONS AND ACCURATE ANSWERS

• The nurse is aware that the older adult client is at an increased

risk for surgical complications due to normal physiological functions and comorbidities. Which risk factors place the older adult client at increased risk for surgical complications?Correct Answer Decreased respiratory muscle strength.

• Upon completing the client's assessment, the nurse determines

that the client has which surgical risk factors? (Select all that apply.)Correct Answer Metroprolol.Poor appetite.Diabetes mellitus.Albumin 3.0g/dL (30 g/L)

• What is the priority preoperative nursing action to prevent

postoperative atelectasis?Correct Answer Instruct on incentive spirometer use.

• Which is the likely reason for the elevated serum creatinine in

the absence of kidney disease?Correct Answer Dehydration.

• The nurse is caring for the client who has just been extubated.

What should the nurse do first, after the client is extubated?Correct Answer Administer supplemental oxygen.

• One hour has passed since the client was extubated. Which

nursing actions take priority at this time? (Select all that apply.)Correct Answer Monitor respiratory rate.Assess cardiac rhythm.

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• Based on the nurse's assessment, which is the priority nursing

action?Correct Answer Administer morphine.

• Based on the healthcare provider's (HCP) prescription, the

pharmacy dispenses morphine 4 mg per 1 mL. How many mL should the nurse administer to the client? (Enter numerical value only. If rounding is required, round to the nearest hundredth.)Correct Answer 0.25

• Upon reviewing the remaining postoperative orders and

comparing with preoperative orders, the nurse realizes that the metformin doses are different. What is the nurse's priority action?Correct Answer Contact the HCP for clarification.

• The client's spouse inquires about the client's blood sugar

because she has never seen it that high, and she reports that the client isn't even eating. What is the nurse's best response?Correct Answer Stress can increase blood sugars.

• After reviewing the client's assessment data, what is the

nurse's priority action?Correct Answer Notify the HCP of the findings.

• The client's spouse asks why the antibiotic is being delayed to

obtain lab tests. What is the nurse's best response?Correct Answer It improves the chance of identifying the bacteria that is making your husband sick.

• Based on the client's respiratory assessment, which is the

priority nursing action?Correct Answer Encourage coughing and deep breathing.

• After giving report, the nurse transfers client back to the

MICU. Which of the client's signs and symptoms cue the MICU 2 / 3

nurse to determine if the client continues to have sepsis? (Select all that apply.)Correct Answer Hypothermia.Altered mental status.Tachycardia.Leukocytosis.Tachypnea.

The HCP orders arterial blood gases (ABGs). The results are as

follows:pH 7.50PaCO2 30 mmHg (3.99 kPa)HCO3 24 mEq/L

(mmol/L)

• The nurse knows that the client is in which acid-base

imbalance?Correct Answer Respiratory alkalosis.

• Which is the primary cause of respiratory alkalosis?Correct

Answer Hypoxemia related to acute lung disorders.

Before the nurse can notify the HCP of the ABG results, the telemetry monitor starts to alarm. It indicates the client is in ventricular tachycardia.

• What is the nurse's first action?Correct Answer Assess the

client.

• Using the American Heart Association's Basic Life Support

(BLS) and Advanced Cardiac Life Support (ACLS) algorithm, what is the nurse's priority action?Correct Answer Assess the carotid artery.

• The nurse assessing the client's carotid artery reports no

pulse is found. What is the nurse's priority action?Correct Answer Activate a code.

• The code team arrives with the crash cart. The carotid artery

is reassessed and there is still no pulse. Cardiac leads are placed, compressions are stopped during rhythm assessment and

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