nurs 371 exam med surg 2022 taking strategies and references questions with answers and rationales
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NURS 371 EXAM MED SURG 2022-taking strategies
and references QUESTIONS WITH ANSWERS AND
RATIONALES
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
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
,NURS 371 EXAM MED SURG 2022-taking strategies
and references QUESTIONS WITH ANSWERS AND
RATIONALES
Client Needs: Physiological Integrity
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 291, 292, 296). St.
Louis: Saunders.
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
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-
,NURS 371 EXAM MED SURG 2022-taking strategies
and references QUESTIONS WITH ANSWERS AND
RATIONALES
red blood” will assist in directing you to the correct option. Remember that the
, NURS 371 EXAM MED SURG 2022-taking strategies
and references QUESTIONS WITH ANSWERS AND
RATIONALES
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.
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
Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is
immediately administered nasally to relieve hypoxemia, respiratory distress, and
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