HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (39 Pages) 100% CORRECT
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Course
HESI
Institution
HESI
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
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hesi extra credit module 9 exam monitoring for health problems new 2022 39 pages 100 correct
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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.
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.
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.
, 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.
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:
, Contacting the physician
Reinserting the chest tube
Transferring the client back to bed
Covering 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 physician. The nurse does not reinsert
the chest tube. The physician will reinsert the chest tube as necessary.
Test-Taking Strategy: Use the process of elimination, noting 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 if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., pp. 648, 649). St. Louis: Saunders. Awarded 1.0
points out of 1.0 possible points.
6.ID: 8482568053A nurse performing nasopharyngeal suctioning and suddenly
notes the presence of bloody secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied Correct
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth
Rationale: The return of bloody secretions is an unexpected outcome of
suctioning. If it occurs, the nurse should first assess the client and then determine the degree of
suction being applied. The degree of suction pressure may need to be decreased. The nurse must
also remember to apply intermittent suction and perform catheter rotation during suctioning.
Continuing the suctioning or performing vigorous suctioning through the mouth will result in
increased trauma and therefore increased bleeding. Suctioning is normally performed on clients
who are unable to expectorate secretions. It is therefore unlikely that the client will be able to
cough out the bloody secretions.
Test-Taking Strategy: Use the process of elimination. Eliminate the options of
continuing the suctioning to remove the blood and removing the suction catheter from the nose
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