Question

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

Answer 1

Correct Answers:

Check the abdominal surgical dressing.

Rationale :

🩸A sudden postoperative BP drop can indicate hemorrhage or fluid loss, so the priority is to assess the surgical site for excessive drainage or bleeding.

🩺In the PACU, the safest first step is direct patient assessment—verifying the dressing, looking under the patient, and evaluating for internal bleeding (distention, firmness, tachycardia).

⏱️Although trends matter, reviewing baseline BP or simply increasing measurement frequency delays action on a potentially life-threatening cause.

📉Encouraging deep breathing addresses oxygenation but does not treat hypotension or identify active bleeding, making it lower priority than checking the dressing.

📌Core message

In a sudden postoperative BP drop, assess for bleeding by checking the surgical dressing first, prioritizing direct assessment over trend review or extra vitals.

Answer 2

Correct Answers:

l will wash my hands with warm soapy water before sticking my finger."

Rationale :

🧼Hand hygiene with warm soapy water removes contaminants like food sugars and lotions and improves circulation, supporting accurate SMBG results.

💧Completely drying the hands prevents dilution of the blood drop, which ensures reliable glucose readings.

🩸The lateral side of the fingertip is preferred for lancing because it is less painful and still provides an adequate sample; using the center of the finger pad is discouraged.

📊Hemoglobin A1c (HbA1c) reflects average glycemia over ~2–3 months and is obtained periodically by laboratory/clinic testing, not daily from an SMBG meter or reported weekly.

📌Core message

Proper SMBG technique means wash and dry hands before lancing, use the side of the finger, and remember HbA1c is a 2–3 month average not a daily meter value.

Answer 3

Correct Answers

Often associated with chronic alcoholism [ Folic acid deficiency anemia ]
Decreased hemoglobin and hematocrit levels [ Folic acid deficiency anemia ; Iron deficiency anemia ; Vitamin B12 deficiency anemia ]
Result of dietary deficiency [ Folic acid deficiency anemia ; Iron deficiency anemia ; Vitamin B12 deficiency anemia ]
Uptake often impeded by medications [ Folic acid deficiency anemia ; Iron deficiency anemia ; Vitamin B12 deficiency anemia ]
Can be caused by malabsorption syndrome [ Folic acid deficiency anemia ; Iron deficiency anemia ; Vitamin B12 deficiency anemia ]

Rationale :

🧩Chronic alcoholism is classically linked with folate deficiency due to poor intake, impaired enterohepatic recycling, and intestinal mucosal injury, making folate-deficiency anemia a frequent sequela.

🍷All three conditions show decreased hemoglobin and hematocrit, because the defining feature of any anemia is reduced oxygen-carrying capacity from a reduced or defective red cell mass.

🧪Dietary deficiency can underlie each: low iron intake (e.g., restrictive diets), insufficient folate (e.g., poor fruits/greens), and inadequate B12 (e.g., strict veganism) can all precipitate anemia.

💊Medications commonly interfere with nutrient absorption or metabolism across all three: PPIs/antacids reduce iron uptake, metformin/acid suppression impair B12 absorption, and methotrexate, trimethoprim, phenytoin antagonize folate pathways.

🚧Malabsorption syndromes can cause any of the three: celiac disease or bariatric surgery impair iron (duodenum) and folate (proximal jejunum), while Crohn’s of the terminal ileum or pernicious anemia (loss of intrinsic factor) impair B12 uptake.

🩸In this case vignette, heavy menses points to iron deficiency, methotrexate raises risk for folate deficiency, and low BMI/limited intake can worsen any nutritional anemia, so understanding overlapping mechanisms is key.

📌Core message

Folate deficiency is often linked to alcoholism, all three show ↓Hgb/↓Hct, each can result from dietary deficiency, many medications impair absorption/metabolism, and malabsorption can cause any of the three.

Answer 4

Correct Answers

Blank 1 Correct Option: Folic acid–deficiency (megaloblastic) anemia
Blank 2 Correct Option: increased mean corpuscular volume and decreased folate.

Rationale :

🔬Increased mean corpuscular volume (MCV) points to macrocytic anemia, which narrows the differential to folate or vitamin B12 deficiency, rather than iron deficiency that is typically microcytic.

📈A concurrently decreased serum folate level specifically supports folic acid–deficiency (megaloblastic) anemia, distinguishing it from vitamin B12 deficiency, where B12 (not folate) is characteristically low.

🍷The client’s regular alcohol intake and low BMI/undernutrition are classic risks for folate deficiency due to impaired intake, absorption, and metabolism.

💊Use of methotrexate (a folate antagonist via dihydrofolate reductase inhibition) further predisposes to folate depletion and megaloblastic changes, making folate deficiency the most consistent choice.

📌Core message

Macrocytosis (↑MCV) plus low folate—with alcohol use and methotrexate—most strongly indicates folic acid–deficiency megaloblastic anemia.

Answer 5

Correct Answers:

Green leafy vegetables
Avocado
Enriched grains
Orange juice
Peanuts

Rationale :

🥬Leafy green vegetables are among the richest sources of folate, directly supporting DNA synthesis and erythropoiesis needed to correct megaloblastic anemia.

🌾Enriched/fortified grains provide synthetic folic acid, which has high bioavailability and is a cornerstone of dietary repletion strategies.

🍊Citrus juices such as orange juice contain naturally occurring folate and also supply vitamin C, supporting overall micronutrient status during recovery.

🥜Legumes (e.g., peanuts) are folate-dense, making them practical additions that increase daily folate intake.

🥑Avocado contributes dietary folate plus healthy fats, aiding caloric repletion in this underweight client.

🚫Beef, potatoes, and vegetable oil are not optimal folate sources (oil contains virtually no folate), so they do not best address folate deficiency anemia compared with the listed folate-rich foods.

📌Core message

Emphasize folate-rich choices—leafy greens, fortified/enriched grains, legumes, citrus, and avocado—to correct folate-deficiency megaloblastic anemia effectively.

Answer 6

Correct Answers:

Record of medication administration
Meal diary
Subjective report from client
Complete blood count

Rationale :

📒A documented medication record is a direct indicator of treatment adherence, showing that the client is taking folic acid, iron, and vitamin C as prescribed.

🥗A meal diary demonstrates behavioral adherence to the folate-rich diet taught (e.g., leafy greens, enriched grains, legumes, citrus), linking daily choices to the plan.

🗣️The client’s subjective report provides self-reported adherence and can clarify timing, dosing, and barriers, which are essential for collaborative adjustment of the plan.

🧪Follow-up CBC results offer objective evidence of adherence/effectiveness, with improving Hgb/Hct and MCV normalization supporting that the regimen is being followed.

📌Core message

Adherence is best demonstrated by documented medication use, a meal diary reflecting the prescribed diet, reliable self-report, and objective CBC improvement.

Answer 7

Correct Answers:

Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

Rationale :

🌊Hypoalbuminemia reduces plasma colloid oncotic pressure, allowing fluid to shift from the intravascular space into the interstitial and peritoneal compartments, producing edema and ascites.

🧪In cirrhosis, impaired hepatic protein synthesis lowers serum albumin, directly weakening the oncotic pull that normally retains fluid within the vasculature.

🧭Although secondary hyperaldosteronism and portal hypertension also contribute to fluid retention, the loss of oncotic pressure is a primary driver of third spacing in many clients.

⚠️Options describing decreased renin-angiotensin activity or reduced portal pressure are inconsistent with cirrhosis, where neurohormonal activation and portal hypertension typically increase.

📌Core message

Cirrhosis lowers albumin, decreasing oncotic pressure and promoting fluid third spacing into edema/ascites.

Answer 8

Correct Answers:

Chest tube insertion.

Rationale :

💨Absent breath sounds with worsening dyspnea after trauma strongly suggests a pneumothorax, necessitating urgent pleural decompression.

🩺A chest tube (thoracostomy) restores negative intrapleural pressure, re-expands the collapsed lung, and evacuates air (and possibly blood).

⏱️While intubation supports the airway, it does not treat the intrapleural air; definitive management requires tube thoracostomy (after needle decompression if tension physiology is suspected).

🔎Tests like bronchoscopy or PFTs are not emergent and would delay lifesaving decompression.

📌Core message

Traumatic pneumothorax with absent breath sounds requires prompt chest tube for lung re-expansion and air evacuation.

Answer 9

Correct Answers:

Neutrophil count.

Rationale :

🧫Purulent drainage from extensive full-thickness burns points to wound infection, making the neutrophil count/ANC the most pertinent lab to assess host response.

📈Elevated or depressed neutrophils (including left shift or neutropenia) informs infection severity, risk of sepsis, and need for escalation.

🧪Values like serum albumin reflect nutrition, and platelets reflect hemostasis, but neither directly gauges the acute infectious process.

⚗️Blood pH may change with sepsis or shock, yet it is nonspecific; the neutrophil profile more directly supports the purulence finding.

📌Core message

Purulent burns warrant checking the neutrophil/ANC to assess bacterial infection and guide urgent management.

Answer 10

Correct Answers:

Report of tight shoes.

Rationale :

🥾Tight shoes imply pedal edema, a hallmark of systemic venous congestion seen in right-sided heart failure.

💧Right-sided failure causes fluid accumulation in the periphery, leading to dependent edema, hepatomegaly, and jugular venous distention.

🌬️Breathlessness is more characteristic of left-sided failure due to pulmonary congestion, while weakness and inactivity are nonspecific.

📏Thus, the shoe-tightness cue specifically directs the nurse to assess further for right-sided signs like weight gain, edema grading, and JVD.

📌Core message

Right-sided HF manifests with peripheral edema—a clue like tight shoes signals systemic venous congestion.

Statement	Folic acid deficiency anemia	Iron deficiency anemia	Vitamin B12 deficiency anemia
Often associated with chronic alcoholism
Decreased hemoglobin and hematocrit levels
Result of dietary deficiency
Uptake often impeded by medications
Can be caused by malabsorption syndrome

HESI RN Med-Surg Fall 2024

No.

1 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 :
A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 :
A nurse is attending to a client.

Correct Answers

4 :
A nurse is taking care of a client.

Correct Answers

5 :
A nurse is assessing a client.

Answer Options

6 :
A nurse is attending to a client.

Answer Options

7 :
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

8 :
A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent fv0

9 :
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?

HESI RN Med-Surg Fall 2024

No.

1 : One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 : A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 : A nurse is attending to a client.

Correct Answers

4 : A nurse is taking care of a client.

Correct Answers

5 : A nurse is assessing a client.

Answer Options

6 : A nurse is attending to a client.

Answer Options

7 : The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

8 : A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent fv0

9 : While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?

1 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 13680 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

2 :
A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and hemoglobin AIC (HbA1 c). Which statement by the client indicates teaching has been effective?

3 :
A nurse is attending to a client.

4 :
A nurse is taking care of a client.

5 :
A nurse is assessing a client.

6 :
A nurse is attending to a client.

7 :
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

8 :
A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the dent fv0

9 :
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider (HCP), the nurse should evaluate which laboratory value?