HESI Exit Practice Questions and Rationale (2), Answers. 2022 update. Graded A+

HESI Exit Practice Questions and Rationale (2), Answers. 2022 update. Graded A+ The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal ...

HESI Exit Practice Questions and Rationale (2), Answers. 2022 update. Graded A+ The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1."Changes in the shape of the knee are expected." 2."Fever, redness, and increased pain are expected." 3."All caregivers should be told about the metal implant." 4."Bleeding gums or black stools may occur, but this is normal." - ✔✔3 A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures. The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1.Capillary refill is less than 3 seconds 2.Pulses present and with swollen, pink fingers 3.Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers - ✔✔3, 4, 5 The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome. A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1.Ice 2.Heat 3.Analgesics 4.Muscle relaxers 5.Intermittent traction - ✔✔2, 3, 4, 5 Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled. The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? 1.Crossing legs at the ankle 2.Using an elevated toilet seat 3.Placing a pillow between the legs 4.Keeping the legs abducted from the midline - ✔✔1 Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times. An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1.Anemia 2.Fractures 3.Infection 4.Muscle sprains - ✔✔2 The client is most at risk for fractures as a result of osteoporosis. Although other complications can occur, fracture is the greatest concern. Anemia and infection can occur with bone marrow disorders, and muscle sprains are unrelated to osteoporosis. A client with a new medication prescription for allopurinol asks the nurse, "I know this is for gout, but how does it work?" The nurse plans to reply based on which medication action? 1.Allopurinol decreases uric acid production. 2.Allopurinol reduces the production of fibrinogen. 3.Allopurinol decreases the risk of sulfa crystal formation in the urine. 4.Allopurinol prevents influx of calcium ions during cell depolarization. - ✔✔1 Allopurinol is classified as an antigout medication. It decreases uric acid production by inhibiting the xanthine oxidase enzyme, and it reduces uric acid concentrations in both serum and urine. The other options are incorrect. The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities? 1.Muscle metabolism and growth 2.Bone resorption and regeneration 3.Nervous system impulse transmission 4.Joint integrity and synovial fluid production - ✔✔2 Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning. A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? 1.Carrots 2.Tapioca 3.Chocolate 4.Chicken liver - ✔✔4 Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout. Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? 1.Platelet count 2.Alkaline phosphatase 3.White blood cell count 4.Complete blood cell count - ✔✔2 Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline phosphatase level and elevated urinary hydroxyproline excretion. The remaining options are unrelated to diagnostic evaluation of this disease. A client is to receive a prescription for methocarbamol. The nurse provides instructions to the client about the medication. Which client statement would indicate a need for further education? 1."My urine may turn brown or green." 2."I might get some nasal congestion from this medication." 3."This medication is prescribed to help relieve my muscle spasms." 4."If my vision becomes blurred, I don't need to be concerned about it." - ✔✔4 Methocarbamol is a muscle relaxant that works by blocking nerve impulses (or pain sensations) that are sent to the brain. The client needs to be told that the urine may turn brown, black, or green. Other adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client needs to be instructed to notify the health care provider if these side/adverse effects occur. The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item should the nurse consider to be most helpful for this client? 1.Television 2.Fracture bedpan 3.Overhead trapeze 4.Reading materials - ✔✔3 The use of an overhead trapeze is extremely helpful for a client to move about in bed and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. Television and reading materials, although helpful in reducing boredom and providing distraction, do not increase bed mobility. A fracture bedpan is useful in reducing discomfort with elimination. The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? 1.Apply ice to the affected area. 2.Perform sterile dressing changes. 3.Instruct the client on leg exercises. 4.Measure the leg circumference daily. - ✔✔2 Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg circumference daily, is not necessary. The health care provider has prescribed a lidocaine 5% patch for a client with a diagnosis of neck pain due to osteoarthritis. Which should the nurse tell the client regarding this medication? 1.The medication patch will act as a local anesthetic. 2.The medication patch acts by decreasing muscle spasms. 3.The medication is prescribed to cause the skin to peel below the patch. 4.Apply a heating pad to the area after applying the medication patch to increase the effectiveness. - ✔✔1 A lidocaine patch provides a local anesthetic effect to the site of application. The medication does not act in a systemic manner. It is not prescribed to cause the skin to peel, so if this reaction occurs, the health care provider should be notified. A heating pad should not be applied because irritation or burning of the skin may occur. The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1.Try to reduce the fracture manually. 2.Assist the victim to get up and walk to the sidewalk. 3.Leave the victim for a few moments to call an ambulance. 4.Stay with the victim and encourage him or her to remain still. - ✔✔4 With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury. The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action? 1.Pulling up using the trapeze 2.Flexing and extending the feet 3.Doing quadriceps-setting and gluteal-setting exercises 4.Performing active range of motion to the right ankle and knee - ✔✔4 Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion. A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1.Fever and bradycardia 2.Fever and hypertension 3.Tachycardia and hypotension 4.Bradycardia and hypertension - ✔✔3 Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension. The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1.Twisting of the spine 2.Curvature of the spine 3.Hyperflexion of the spine 4.Sciatic nerve inflammation 5.Degeneration of the facet joints 6.Herniation of an intervertebral disk - ✔✔1, 3, 6 Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk. A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess? 1.The injection site for itching and edema 2.The white blood cell counts and platelet counts 3.Whether the client is experiencing fatigue and joint pain 4.Whether the client is experiencing a metallic taste in the mouth, and a loss of appetite - ✔✔2 Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of adverse effects of this medication. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1.Myxedema 2.Kidney disease 3.Hypothyroidism 4.Diabetes mellitus - ✔✔2 Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication. The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1.Dependent edema 2.Diminished distal pulse 3.Presence of a "hot spot" on the cast 4.Coolness and pallor of the extremity - ✔✔3 Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema. The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect should the nurse monitor? 1.Tachycardia 2.Rapid pulse 3.Bradycardia 4.Hypertension - ✔✔3 Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication. The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? 1.Elevating the limb 2.Monitoring vital signs every 4 hours 3.Administering opioid analgesics intramuscularly 4.Monitoring the biopsy site for swelling, bleeding, or hematoma - ✔✔3 Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours or as prescribed to reduce edema. The vital signs are monitored every 4 hours for 24 hours for signs of complications such as infection and bleeding. The client usually requires mild analgesics. More severe pain usually indicates that complications are arising. The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1.Provide pin care. 2.Medicate the client. 3.Call the health care provider. 4.Remove 2 pounds (0.9 kg) of weight from the traction system. - ✔✔3 Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so. The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1.A trochanter roll to prevent abduction during turning 2.A pillow to keep the right leg abducted during turning 3.A pillow to keep the right leg adducted during turning 4.A trochanter roll to prevent external rotation during turning - ✔✔2 After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned. The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 1.Pressure on the spinal cord 2.Pressure on the spinal nerve root 3.Muscle spasm in the area of the herniated disk 4.Excess cerebrospinal fluid production in the area - ✔✔3 Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Pressure on a spinal nerve root causes the symptoms of sciatica. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position - ✔✔3 Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound. An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? 1.Heels 2.Sacrum 3.Back of the head 4.Greater trochanter - ✔✔4 The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae. The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1.Nerve damage 2.Hypertrophy of collagen fibers 3.Compromised circulation at the burn site 4.Increase in subcutaneous tissue at the burn site - ✔✔2 Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve. The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? 1.Venous stars noted on trunk and thighs 2.Spider angiomas observed on trunk and thighs 3.Appears to have purpura on trunk and thighs 4.Appears to have cherry angiomas on trunk and thighs - ✔✔4 A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin. The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client? 1.The presence of blisters 2.The presence of white patches 3.The presence of purple patches 4.The presence of numerous small, red, pinpoint lesions - ✔✔2 Assessment of the client with candidiasis (thrush) will reveal white patches on the tongue, palate, and buccal mucosa. The lesions adhere firmly to the tissues and are difficult to remove. The lesions often are referred to as "milk curds" because of their appearance. Clients often describe the lesions as dry and hot. Options 1, 3, and 4 are not characteristics of thrush. A client is on nothing by mouth (NPO) status and has a nasogastric (NG) tube in place after suffering bilateral burns to the legs. The nurse determines that the client's gastrointestinal (GI) status is least satisfactory if which finding is noted on assessment? 1.Gastric pH of 3 2.Absence of abdominal discomfort 3.GI drainage that is guaiac negative 4.Presence of hypoactive bowel sounds - ✔✔The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine 2 (H2) receptor-blocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. Absence of discomfort and bleeding (guaiac-negative drainage) are normal findings. The client's bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.Fiery red skin with edema in the nail beds 3.Black fingertips surrounded by an erythematous rash 4.A white color to the skin, which is insensitive to touch - ✔✔4 Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect. A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? 1.Anemia 2.Hypothyroidism 3.Diabetes mellitus 4.Chronic kidney disease - ✔✔4 Clients with chronic kidney disease often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown. The nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which statement, if made by the client, would indicate a need for further instruction? 1."I will keep the dressing dry." 2."I will watch for any drainage from the wound." 3."I will use the antibiotic ointment as prescribed." 4."I will return tomorrow to have the sutures removed." - ✔✔4 Sutures usually are removed 7 to 10 days after a skin biopsy, depending on health care provider (HCP) preference. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours as prescribed. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The HCP may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. The site may be closed with sutures or may be allowed to heal without suturing. The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? 1.Nails 2.Hair follicles 3.Pilosebaceous glands 4.Epithelial layer of skin - ✔✔1 Paronychia is a fungal infection that most often is caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The affected area generally is tender to touch and has purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. A variety of disorders may involve the epithelial skin layer. The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? 1.Ensure that the consent form has been signed. 2.Ensure that a Foley catheter has been inserted. 3.Provide chlorhexidine wipes to be used before the procedure. 4.Verify the blood bank has 1 unit of packed red blood cells available if needed. - ✔✔1 A punch biopsy involves use of a punch instrument that punctures the skin and is rotated to obtain some of the dermis and fat. It is used for diagnostic purposes. A signed consent form is required for this procedure. A Foley catheter is not indicated and should be avoided if possible for any condition or procedure due to the risk for catheter-associated urinary tract infection. Chlorhexidine wipes are not specifically indicated for this procedure; usually an antibacterial such as povidone-iodine is used. There is not typically a lot of bleeding with this procedure; therefore, units of blood are not typically made available for the client undergoing punch biopsy. he nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? 1.Pallor 2.Cyanosis 3.Erythema 4.Jaundice - ✔✔3 Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2, and 4 are not signs or symptoms of cellulitis. The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? 1.Acne 2.Freckles 3.Psoriasis 4.Sebaceous cysts - ✔✔1 Acne is characterized by vesicles filled with cloudy or purulent fluid. Freckles are flat lesions less than 1 centimeter. Psoriasis is presented by elevated, plateaulike patches more than 1 centimeter. Sebaceous cysts are nodules filled with either liquid or semisolid material that can be expressed. A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? 1.Eschar 2.Intact blisters 3.Liquefaction necrosis 4.Cherry-red, firm tissue - ✔✔3 Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury. The nurse in the ambulatory care clinic is reviewing a plan of care for a client who will be returning from the postanesthesia care unit after a blepharoplasty. Which nursing interventions should be a component of the postoperative care plan for this client? Select all that apply. 1.Monitoring for swelling 2.Elevating the head of the bed 3.Applying warm gauze pads to the eyes 4.Instructing the client to avoid Valsalva maneuvers 5.Assessing the function of the extraocular eye muscles - ✔✔1, 2, 4, 5 Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Postoperatively, the client is assessed for swelling, bruising, bleeding, and eye pain. The head of the bed should be elevated, and cool eye compresses are applied to the area to reduce swelling. The client is instructed to avoid the Valsalva maneuver, which increases intracranial pressure and also pressure in the head and eye, thereby increasing the risk of hemorrhage. The function of extraocular eye muscles also is assessed. Gauze pads are not used because cotton is thick and pulls the skin when it is removed; in addition, warm compresses will increase