Questions
1. ID: 5A 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 immediately:
Contacts the physician Documents the ...
,Questions
1. ID: 8482572285A 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 immediately:
Contacts the physician
Documents the findings
Places the client in a supine position with the legs flat
Covers 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 physician is notified, and the nurse documents the occurrence
and the nursing actions that were implemented in response.
Test-Taking Strategy: Use the process of elimination and note the strategic word
“immediately.” 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 if
you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 291, 292, 296). St. Louis: Saunders.
Awarded
1.0 points out of 1.0 possible points.
2. ID: 8482572275A client who just returned from the recovery room after a
tonsillectomy and adenoidectomy is restless and her pulse rate is increased. As the nurse
continues the assessment, the client begins to vomit a copious amount of bright-red blood.
The immediate nursing action is to:
Notify the surgeon Correct
Continue the assessment
Check the client’s blood pressure
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: Focus on the data in the question. 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 if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 657). St. Louis: Saunders. Awarded 1.0 points
out of 1.0 possible points.
3. ID: 8482570090A 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:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula Correct
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 physician is 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.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of
prioritizing. Apply 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 if you
had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
, Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 680). St. Louis: Saunders. Awarded 1.0 points
out of 1.0 possible points.
4. ID: 8482572237A 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).
Clamping the chest tube
Changing the drainage system
Assessing the system for an external air leak Correct
Reducing the degree of suction being applied
Documenting 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 physician 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: Use the process of elimination and your knowledge
regarding the priority actions in the care of a closed chest tube drainage system. Focus on the
data in the question, noting that there is bubbling in the water seal chamber. Recalling that this
may indicate an air leak will direct you to the correct options. Review the nursing actions to be
taken immediately in the event that complications of a closed chest tube drainage system occur
if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 648, 649). St. Louis: Saunders.
Awarded 2.0 points out of 2.0 possible points.
5. ID: 8482572257A 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. The immediate priority on the part of the nurse
is:
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