1. ID: 383740621
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 immediately:
Contacts the physician Answers
available here
https://bit.ly/2VkWqmT
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
2. ID: 383740621
A 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 Continue the
assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved
hemostat
3. ID: 383739348 Answers available here
https://bit.ly/2VkWqmT
, lOMoARcPSD|784381
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:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
Ensuring that the intravenous (IV) line is patent
4.ID: 383738703
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).
Clamping the chest tube Answers
available here
https://bit.ly/2VkWqmTChang
ing the drainage system
Assessing the system for an external air leak
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
5.ID: 383739392
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. 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
6.ID: 383737764
, lOMoARcPSD|784381
A 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 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
Answers available here https://bit.ly/2VkWqmT
7. ID: 383737791
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
Contact the physician
Administer a
bronchodilator
Disconnect the suction source from the catheter
8. ID: 383739364
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24
hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The
nurse first:
Contacts the physician
Checks for kinks in the drainage system Checks
the client’s blood pressure and heart rate
Connects a new drainage system to the client’s chest tube
Answers available here https://bit.ly/2VkWqmT
9. ID: 383740435
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s
urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:
Calls the physician
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