HESI Extra Credit Module 9
1. Questions
1. 1.ID: 8
A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take whi...
hesi extra credit module 9 1 questions 1 1id 9477047208 a client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision
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HESI Extra Credit Module 9
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HESI Extra Credit Module 9
1. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and
reports that she just felt “something give way” in the abdominal
incision. The nurse checks the incision and notes the presence of
wound dehiscence. The nurse should take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing
moistened with sterile saline solution Correct
Rationale: Wound dehiscence is the disruption of a surgical incision
or wound. When dehiscence occurs, the nurse immediately places
the client in a low Fowler’s position or supine with the knees bent
and instructs the client to lie quietly. These actions will minimize
protrusion of the underlying tissues. The nurse then covers the
wound with a sterile dressing moistened with sterile saline. The
health care provider is notified, and the nurse documents the
occurrence and the nursing actions that were implemented in
response.
Test-Taking Strategy: Note the strategic word “immediate.” Visualize
this occurrence and recall that the primary concern when wound
dehiscence occurs is the protrusion of underlying tissues. This will
direct you to the correct option. Review the nursing actions to be
taken immediately in the event of wound dehiscence
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Caregiving, Tissue
Integrity HESI Concepts: Caregiving, Tissue
Integrity
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9477054249
A client who just returned from the recovery room after a
tonsillectomy and adenoidectomy is restless and the pulse rate
is increased. As the nurse continues the assessment, the client
begins to vomit a copious amount of bright-red blood. The nurse
should take which immediate action?
A. Notify the surgeon Correct
B. Continue the assessment
, C. Check the client’s blood pressure
D. Obtain a flashlight, gauze, and a curved hemostat
Rationale: Hemorrhage is a potential complication after tonsillectomy
and adenoidectomy. If the client vomits a large amount of bright-red
blood or the pulse rate increases and the patient is restless, the
nurse must notify the surgeon immediately. The nurse should obtain
a light, mirror, gauze, curved hemostat, and waste basin to facilitate
examination of the surgical site. The nurse should also gather
additional assessment data, but the surgeon must be contacted
immediately.
Test-Taking Strategy: Note the strategic word, immediate. Noting the
words “bright-red blood” will assist in directing you to the correct
option. Remember that the presence of bright-red blood indicates
active bleeding. Review the nursing actions to be taken
immediately when bleeding occurs after a tonsillectomy and
adenoidectomy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Collaboration, Clotting
HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
A client who has just undergone surgery suddenly experiences
chest pain, dyspnea, and tachypnea. The nurse suspects that the
client has a pulmonary embolism and immediately sets about to
take which action?
A. Preparing the client for a perfusion scan
B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula Correct
D. Ensuring that the intravenous (IV) line is patent
Rationale: Pulmonary embolism is a life-threatening emergency.
Oxygen is immediately administered nasally to relieve hypoxemia,
respiratory distress, and central cyanosis, and the
health care provideris notified. IV infusion lines are needed to
administer medications or fluids. A perfusion scan, among other
tests, may be performed. The electrocardiogram is monitored for
the presence of dysrhythmias.
Additionally, a urinary catheter may be inserted and blood for
arterial blood gas determinations drawn. The immediate priority,
however, is the administration of oxygen.
, prioritizing. Use the ABCs (airway, breathing, and circulation) to find
the correct option. Review the nursing actions to be taken
immediately in the event of pulmonary embolism
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 552). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
A nurse is assessing a client who has a closed chest tube
drainage system. The nurse notes constant bubbling in the water
seal chamber. What actions should the nurse take? (Select all that
apply).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and
client response Correct
Rationale: Constant bubbling in the water seal chamber of a closed
chest tube drainage system may indicate the presence of an air
leak. The nurse would assess the chest tube system for the
presence of an external air leak if constant bubbling were noted in
this chamber. If an external air leak is not present and the air leak is
a new occurrence, the health care provider is notified immediately,
because an air leak may be present in the pleural space. Leakage
and trapping of air in the pleural space can result in a tension
pneumothorax. Clamping the chest tube is incorrect. Additionally, a
chest tube is not clamped unless this has been specifically
prescribed in the agency’s policies and procedures. Changing the
drainage system will not alleviate the problem. Reducing the degree
of suction being applied will not affect the bubbling in the water seal
chamber and could be harmful. The nurse would document the
assessment findings and interventions taken in the client’s medical
record.
Test-Taking Strategy: Focus on the data in the question, noting that
there is bubbling in the water seal chamber. Use knowledge
, nursing actions to be taken immediately in the event that
complications of a closed chest tube drainage system occur
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
A nurse is helping a client with a closed chest tube drainage system
get out of bed and into a chair. During the transfer, the chest tube is
caught on the leg of the chair and dislodged from the insertion site.
What is the immediate nursing action?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover the insertion site with a sterile occlusive dressing
Correct
Rationale: If a chest tube is dislodged from the insertion site, the
nurse immediately covers the site with sterile occlusive dressing. The
nurse then performs a respiratory assessment, helps the client back
into bed, and contacts the health care provider. The nurse does not
reinsert the chest tube. The health care provider
will reinsert the chest tube as necessary.
Test-Taking Strategy: Note the strategic word “immediate.” Eliminate
the option that involves reinsertion of the chest tube first, because a
nurse is not trained to insert a chest tube. To select from the
remaining options, focus on the subject, dislodgment of a chest tube
from its insertion site, and recall the complications associated with
this occurrence; this will direct you to the correct option.
Review the nursing actions to be taken immediately in the
event of complications associated with a closed chest tube
drainage system Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
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