HESI Fundamentals - Set 5 - Part 1

Correct Answer: Explain the procedure, risks, and alternatives

Explaining the procedure, risks, alternatives, and expected outcomes is the surgeon's responsibility. The nurse witnesses the signing, confirms the patient is alert and not impaired, and notifies the surgeon if questions arise. Option a is incorrect because Witnessing the patient signing the consent form is part of the nurse's role. The action confirms identity and signature, but does not include explaining the procedure or providing the medical detail to the patient. Option b is incorrect because Confirming alertness and observing the signature are nursing responsibilities. The nurse does this work to verify capacity at the moment of signing, but does not provide the medical explanation that grounds the consent. Option d is incorrect because Placing the consent in the chart is part of completing the process. The action does not constitute informed consent itself, which depends on the surgeon's prior explanation and the patient's understanding of what was shared.

Correct Answer: Reduces aspiration risk during anesthesia

An empty stomach reduces aspiration risk during induction of anesthesia. Loss of airway reflexes during induction creates the danger, and following NPO timing protects the patient from a serious complication during the surgical event. Option b is incorrect because NPO status does not improve wound healing. Wound healing depends on perioperative nutrition, perfusion, and infection control rather than on the few hours of fasting before the operating room arrival. Option c is incorrect because NPO status does not lower blood loss during surgery. Blood loss is influenced by surgical technique, coagulation status, and other factors, none of which are affected by withholding food before the case. Option d is incorrect because NPO status does not prevent postoperative urinary retention. Retention is influenced by anesthetic agents, opioids, and bladder distention, not by the empty stomach maintained for airway safety during induction.

Correct Answer: Surgeon marks the site with patient awake

The surgeon marks the operative site with the patient awake and able to confirm. The mark stays visible after prep, and a time-out in the operating room verifies patient, procedure, and site before the incision. Option a is incorrect because Verbal confirmation only on the day before does not meet the safety standard. The mark on the patient is part of the process, along with the chart, the patient confirmation, and the time-out together. Option b is incorrect because Allowing the operating room team to mark the site without the surgeon misses the responsible person. The surgeon performs the marking with the patient awake to verify the correct site before any sedation. Option c is incorrect because Relying on the chart note for site identification has caused wrong-site surgery in the past. The mark on the body is required because charts can contain errors that go uncaught without a physical confirmation.

Correct Answer: Use incentive spirometer and deep breathing

Teaching incentive spirometer use, deep breathing, and coughing reduces atelectasis and pneumonia after surgery. Patients who learn these techniques before surgery use them more reliably while recovering and avoid common pulmonary complications during the hospital stay. Option a is incorrect because Avoiding movement for several days worsens pulmonary and circulatory complications. Early mobilization reduces atelectasis, pneumonia, and venous thromboembolism risk, so the teaching should encourage activity rather than prolonged immobility after surgery. Option c is incorrect because Skipping cough technique due to pain risk leaves the patient unable to clear secretions effectively. The nurse teaches splinting with a pillow and pairs analgesia with cough so the patient can perform the maneuver safely. Option d is incorrect because Relying solely on the nurse to perform exercises produces poor outcomes. Self-directed pulmonary hygiene is essential between nurse interactions, and the patie

Correct Answer: Listen actively and provide accurate information

Active listening and accurate information address the patient's underlying concerns. The nurse acknowledges feelings, answers questions within scope, and arranges a surgeon visit for medical specifics, helping the patient enter surgery feeling prepared and supported. Option a is incorrect because Telling the patient that anxiety is unhelpful dismisses the concern and damages trust. The response shuts down communication rather than helping the patient process worry, and it leaves anxiety unaddressed before the operative event. Option b is incorrect because Distraction with unrelated topics may briefly reduce focus on the surgery, but it does not resolve the underlying worry. Patients often want concrete information to feel prepared, not pure avoidance of the topic. Option d is incorrect because Recommending an immediate sedative without consulting the provider exceeds nursing scope and skips important steps. The nurse first uses non-pharmacologic measures, and any anti-anxiety medi

Correct Answer: Assess airway patency and oxygenation

Airway patency and oxygenation are the first PACU priorities because anesthesia depresses respiratory drive and airway reflexes. The nurse positions the patient, applies oxygen, and monitors for obstruction or hypoventilation during the early recovery period. Option b is incorrect because Discharge teaching is not appropriate for a patient still emerging from anesthesia. Teaching depends on the patient being alert and able to retain information, neither of which is true at this moment of recovery. Option c is incorrect because Encouraging ambulation right away is unsafe in a patient who is not fully arousable. The patient needs continued monitoring of airway, breathing, and circulation before any mobilization is attempted at the bedside or chair. Option d is incorrect because Documenting the procedure description is important but not the immediate priority. The nurse stabilizes airway, breathing, and circulation first, and documentation follows once safety has been ensured during the i

Correct Answer: Incentive spirometry, deep breathing, ambulation

Incentive spirometry, deep breathing, coughing, and early ambulation expand the lungs and prevent atelectasis. Adequate analgesia supports the actions, since pain limits movement and breathing depth, and the team coordinates these measures every shift consistently. Option a is incorrect because Bed rest with no ambulation or cough invites atelectasis and pneumonia. The lungs collapse with shallow breathing and pooled secretions, which is exactly what early mobility and coughing maneuvers are designed to prevent here. Option b is incorrect because Restricting fluid intake worsens secretion thickness and slows clearance. The patient needs adequate hydration to keep mucus thin enough to mobilize, except in specific situations like fluid overload requiring restriction in the plan. Option c is incorrect because Preventing analgesia leaves the patient in pain and unable to participate in pulmonary hygiene. The nurse provides pain control so the patient can take deep breaths, cough, and ambul

Correct Answer: Apply pressure, notify provider, monitor vitals

Increased saturation, hypotension, and tachycardia suggest postoperative bleeding. The nurse applies direct pressure, notifies the provider, monitors vital signs, prepares fluids and possible blood products, and watches for signs of progression toward shock. Option a is incorrect because Documenting and continuing routine assessment misses a developing emergency. The findings call for immediate intervention and escalation rather than passive observation, since hemorrhage worsens quickly and the patient can deteriorate during the wait. Option b is incorrect because Encouraging walking around the room is unsafe with active bleeding and dropping pressure. Mobility increases blood loss and the patient may collapse during ambulation, making the action contraindicated in the current situation. Option d is incorrect because Stopping intravenous fluids worsens hypovolemia from blood loss. The patient needs more volume, not less, and the nurse should anticipate orders for fluid resuscitation an

Correct Answer: Hypoxia from atelectasis or shallow breathing

Restlessness and confusion paired with low saturation point to hypoxia, often from atelectasis or shallow postoperative breathing. The nurse applies oxygen, repositions the patient, encourages deep breathing, and reassesses to confirm improvement during the response. Option a is incorrect because Normal post-anesthesia behavior does not include sustained restlessness with confusion and low saturation. The pattern is pathologic and warrants investigation rather than dismissal as a benign anesthesia recovery effect at this point. Option c is incorrect because Routine restlessness from boredom does not lower oxygen saturation. The pulse oximeter result is the key cue that something more than emotional state is occurring with the patient at this point in recovery. Option d is incorrect because Anxiety alone does not produce a saturation in the eighties. The numbers point to a physiologic problem, even though anxiety could contribute to restlessness, so the nurse must address oxygenation ra

Correct Answer: Encourage ambulation and reassess bowel sounds

Encouraging ambulation, withholding solid intake until bowel function returns, and reassessing bowel sounds are appropriate independent measures. The nurse coordinates with the provider on intravenous fluids, electrolytes, and any pharmacologic agents to support recovery. Option b is incorrect because Pushing large meals before bowel function returns worsens distention and triggers vomiting. The patient should remain on limited intake until peristalsis is documented, advancing slowly per orders rather than feeding aggressively in this situation. Option c is incorrect because Giving a large oral fluid bolus risks distention and aspiration in a non-functioning gut. The patient typically receives intravenous fluids while bowel function returns rather than oral fluids in large amounts at this point. Option d is incorrect because Administering a cathartic without a provider order exceeds nursing scope. The decision to use a stimulant or other agent depends on clinical judgment by the prescr

Correct Answer: Hemostasis, inflammation, proliferation, maturation

The wound healing phases proceed as hemostasis, inflammation, proliferation, and maturation. The nurse recognizes each phase by its timeline and signs, supporting the patient with appropriate dressings and education during each stage of recovery. Option a is incorrect because Maturation is the final phase, not the first. The order described starts at the end and works backward, which does not match the actual physiologic progression of wound healing in any patient. Option b is incorrect because Proliferation does not begin before hemostasis and inflammation. The body must first stop bleeding and clear debris before new tissue can form, so this order misrepresents the actual sequence of healing. Option c is incorrect because Inflammation does not occur before hemostasis. The bleeding stops first, then the inflammatory phase begins to clear bacteria and debris, so the order in this option does not match physiology accurately.

Correct Answer: Redness, edema, ecchymosis, drainage, approximation

REEDA stands for redness, edema, ecchymosis, drainage, and approximation. The structured framework supports systematic wound assessment, helping the nurse identify infection, hematoma, dehiscence, or normal healing during each visit and document findings clearly. Option a is incorrect because Rest, eat, elevate, document, ambulate is not the REEDA acronym. The wording in the option does not match the standard wound assessment framework used in nursing practice for surgical and traumatic wounds. Option b is incorrect because Reach, examine, evaluate, document, assess is not REEDA. The actual meaning of each letter ties to specific wound findings, so general assessment verbs do not constitute the structured framework in question. Option d is incorrect because Range, edge, expansion, depth, approximation does not match REEDA. The framework specifically uses redness, edema, ecchymosis, drainage, and approximation to capture the most relevant signs of healing or complication after surgery.

Correct Answer: Empty the bulb, then compress, then close

Empty the bulb, compress it to remove air, then close the cap. The compressed bulb creates the gentle suction that pulls fluid from the wound, and the cycle is repeated each shift to keep drainage flowing. Option b is incorrect because Leaving the bulb fully expanded after emptying eliminates the suction. Without compression, the drain cannot pull fluid from the wound, and accumulated fluid may delay healing or contribute to infection at the site. Option c is incorrect because Compressing the bulb without emptying first does not create new suction because the bulb is already partially full. The fluid must be measured and discarded before recompression establishes the negative pressure on the system. Option d is incorrect because Disconnecting the drain to vent introduces contamination and breaks the closed system. The drain should remain a closed system to reduce infection, so disconnection is not part of routine emptying or maintenance.

Correct Answer: Cover with saline gauze, low Fowler

Cover the eviscerated bowel with sterile saline-soaked gauze and place the patient in low Fowler with knees flexed to reduce abdominal tension. The team prepares for emergency surgical repair while monitoring for shock and signs of infection. Option a is incorrect because Pushing the bowel back inside risks contamination and perforation. The nurse leaves the protruding tissue covered with moistened sterile dressings while the surgical team prepares for repair in the operating room as soon as possible. Option b is incorrect because Applying dry sterile gauze allows the bowel to dry out and adhere to the gauze. Saline-moistened gauze keeps the tissue viable until the patient can reach the operating room for repair. Option c is incorrect because Encouraging the patient to walk worsens evisceration and increases abdominal pressure. The patient must remain still in low Fowler with the wound covered, awaiting transport to the operating room as soon as available.

Correct Answer: Notify provider, obtain culture, plan antibiotics

Increased redness, warmth, purulent drainage, fever, and pain suggest wound infection. The nurse notifies the provider, obtains a wound culture per orders, and anticipates antibiotic therapy along with continued local wound care during the response. Option a is incorrect because Continuing routine care without escalation misses a developing infection. The findings require provider notification and additional steps, since infection can progress to systemic involvement if not addressed promptly during the early stage seen here. Option b is incorrect because Applying topical lotion to soothe the area can introduce irritants and is not standard wound care. The nurse follows the prescribed wound care plan, which uses sterile cleansing and appropriate dressings instead of comfort lotions. Option d is incorrect because Covering the wound and avoiding inspection conceals worsening signs and delays treatment. The nurse should examine the wound carefully, document findings, and notify the provid

Correct Answer: Reduces venous thromboembolism and pneumonia risk

Early ambulation reduces venous thromboembolism, atelectasis, pneumonia, ileus, and deconditioning. The action improves circulation, ventilation, and bowel motility, helping the patient recover faster and avoid the most common postoperative complications during the stay. Option a is incorrect because Early ambulation supports rather than reduces wound healing through improved perfusion. The option misstates the effect, since gentle activity brings oxygen and nutrients to the healing tissue and promotes recovery overall. Option c is incorrect because Pain may briefly increase with movement but is managed through analgesia and pacing. The benefit of early mobility outweighs the discomfort, and the nurse coordinates pain control to allow movement without unnecessary suffering. Option d is incorrect because Early ambulation supports the return of bowel function rather than preventing it. Walking stimulates peristalsis and helps prevent ileus, which is one of the standard reasons to mobiliz

Correct Answer: Apply over both legs, ensure no twisting

Sequential compression devices are applied to both legs unless contraindicated, with sleeves smooth and untwisted. The nurse checks skin under the sleeves, removes them only as ordered, and inspects pulses and skin during periodic checks. Option b is incorrect because Wrapping the device directly over open wounds traumatizes the wound and contaminates the sleeves. Open lesions, ischemia, and recent vascular surgery are typical contraindications to applying compression sleeves to that limb. Option c is incorrect because Using on only one leg leaves the other limb without protection. Both legs are at risk for clot formation, and bilateral application is the standard practice unless a specific contraindication exists for one side. Option d is incorrect because Leaving the device on permanently without breaks risks skin breakdown and pressure injury. The nurse removes sleeves periodically per institutional policy to inspect skin and confirm continued appropriate function during the stay.

Correct Answer: Ankle pumps, knee flexion, quad sets

Ankle pumps, knee flexion, and quadriceps sets stimulate calf muscle pumping and venous return. The exercises are simple, safe, and can be done frequently in bed to reduce the risk of venous thromboembolism between walks. Option a is incorrect because Holding both legs perfectly still all day promotes venous stasis. The action contradicts the very purpose of postoperative leg exercises, which is to keep blood moving and prevent clot formation during periods of immobility. Option b is incorrect because Lifting one leg straight up forcefully is not a standard postoperative leg exercise and may cause incision pain. The recommended exercises are gentler and focus on muscle pumping rather than maximal effort against gravity. Option c is incorrect because Tightening abdominal muscles only does not address calf venous return. While abdominal exercises support recovery in some contexts, they do not match the goal of preventing thromboembolism through calf muscle pumping action.

Correct Answer: Avoid crossing legs and use abductor pillow

Avoiding leg crossing and using an abductor pillow keep the new hip in safe alignment. The patient also avoids hip flexion past ninety degrees, internal rotation, and adduction during the early healing period after the posterior approach. Option a is incorrect because Crossing legs and rotating the operative leg inward both place the prosthesis at high risk of dislocation. The patient must keep the legs apart and avoid internal rotation during the early postoperative recovery weeks. Option b is incorrect because Bending the hip past ninety degrees can dislocate the prosthesis after a posterior approach. The patient must avoid extreme hip flexion during sitting, transfers, and toileting throughout the early healing period. Option d is incorrect because Sitting on a low couch forces the hip into deep flexion, increasing dislocation risk. The patient should use a higher chair with arms to keep the hip below the recommended flexion limit during healing.

Correct Answer: New unstable hemodynamics or active bleeding

Unstable hemodynamics, active bleeding, or specific surgical restrictions are reasons to consult the provider before ambulation. The patient could deteriorate with movement, and the team must confirm safety before mobilizing in these situations on the unit. Option b is incorrect because Stable vital signs and minimal pain are reasons to encourage ambulation. The patient is a good candidate for getting out of bed, and the nurse can mobilize without further provider consultation in this scenario. Option c is incorrect because Successful pain control and clear thinking support safe ambulation. The patient can participate in the activity safely, and the nurse can implement standard mobility care without delay or additional consultation in this case. Option d is incorrect because Full recovery from anesthesia clears the patient for ambulation under standard precautions. The nurse can mobilize the patient with usual safety measures, and additional provider consultation is not required for th