A client who has undergone abdominal surgery calls the nurse and reports that she just felt ID: 18630135763
“something give way” in the abdominal
... [Show More] incision. The nurse checks the incision and notes the presence of
wound dehiscence. The nurse immediately takes which action?
A. Contacts the health care provider
B. Documents the findings
C. Places the client in a supine position with the legs flat
D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution C Co or rr re ec ct t
Rationale: Rationale: W Wound dehiscence is the disruption of a surgical incision or wound. When ound dehiscence is the disruption of a surgical incision or wound. When
dehiscence occurs, the nurse immediately places the client in a low Fowler position or supine dehiscence occurs, the nurse immediately places the client in a low Fowler position or supine
with the knees bent and instructs the client to lie quietly with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion . These actions will minimize protrusion
of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened 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 with sterile saline. The health care provider is notified, and the nurse documents the occurrence
and the nursing actions that were implemented in response. and the nursing actions that were implemented in response.
T Test-T est-Taking Strategy: aking Strategy: Use Use the process of elimination and note the strategic word “immediately the process of elimination and note the strategic word “immediately.” .”
V Visualize this occurrence and recall that the primary concern when wound dehiscence occurs is isualize 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 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 dif actions to be taken immediately in the event of wound dehiscence if you had difficulty with this ficulty with this
question. question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Perioperative Care Perioperative Care
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
1.A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is ID: 18630135725
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. Which is the immediate nursing action?
A. Notify the surgeon. C Co or rr re ec ct t
Rationale: Rationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the . If the
client vomits a large amount of bright-red blood or the pulse rate increases and the patient is 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 restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror . The nurse should obtain a light, mirror, ,
gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. The nurse
should also gather additional data, but the surgeon must be contacted immediately should also gather additional data, but the surgeon must be contacted immediately. .
T Test-T est-Taking Strategy: aking Strategy: Focus on the data in the question. Noting the words “bright-red blood” will 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 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 indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had dif occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question. ficulty with this question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Delegating/Prioritizing Delegating/Prioritizing
B. Auscultate the lungs.
C. Check the client’s blood pressure.
D. Obtain a flashlight, gauze, and a curved hemostat.
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
2.
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and ID: 18630135170
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately takes 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 C Co or rr re ec ct t
Rationale: Rationale: Pulmonary embolism is a life-threatening emergency Pulmonary embolism is a life-threatening emergency. Oxygen is immediately . Oxygen is immediately
administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the administered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and the
health care provider is notified. IV infusion lines are needed to administer medications or fluids. health care provider 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 A perfusion scan, among other tests, may be performed. The electrocardiogram is monitored for
the presence of dysrhythmias. Additionally the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood for , a urinary catheter may be inserted and blood for
arterial blood gas determinations drawn. The immediate priority arterial blood gas determinations drawn. The immediate priority, however , however, is the administration , is the administration
of oxygen. of oxygen.
3.T Test-T est-Taking Strategy: aking Strategy: Focus on the client’ Focus on the client’s diagnosis and use the skills of prioritizing. Apply the s diagnosis and use the skills of prioritizing. Apply the
ABCs (airway ABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actions , 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 dif to be taken immediately in the event of pulmonary embolism if you had difficulty with this ficulty with this
question. question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Delegating/Prioritizing Delegating/Prioritizing
D. Ensuring that the intravenous (IV) line is patent
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes ID: 18630135190
constant bubbling in the water seal chamber. What actions should the nurse take? Select all that apply.
A. Clamping the chest tube
B. Changing the drainage system
C. Assessing the system for an external air leak C Co or rr re ec ct t
D. Reducing the degree of suction being applied
E. Documenting assessment findings, actions taken, and client response C Co or rr re ec ct t
Rationale: Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may 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 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 an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present . 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 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 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 tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped , a chest tube is not clamped
unless this has been specifically prescribed in the agency’ unless this has been specifically prescribed in the agency’s policies and procedures. Changing the s policies and procedures. Changing the
drainage system will not alleviate the problem. Reducing the degree of suction being applied will not drainage system will not alleviate the problem. Reducing the degree of suction being applied will not
af affect the bubbling in the water seal chamber and could be harmful. The nurse would document the fect the bubbling in the water seal chamber and could be harmful. The nurse would document the
assessment findings and interventions taken in the client’ assessment findings and interventions taken in the client’s medical record. s medical record.
T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination and your knowledge regarding the priority actions 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 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 is bubbling in the water seal chamber. Recalling that this may indicate an air leak will direct you to the . 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 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 dif closed chest tube drainage system occur if you had difficulty with this question. ficulty with this question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
4.Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory
A Awarded 2.0 points out of 2.0 possible points. warded 2.0 points out of 2.0 possible points.
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a ID: 18630135172
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 which action?
A. Contacting the health care provider
B. Reinserting the chest tube
C. Transferring the client back to bed
D. Covering the insertion site with a sterile occlusive dressing C Co or rr re ec ct t
Rationale: Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the 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 site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the
client back into bed, and contacts the health care provider client back into bed, and contacts the health care provider. The nurse does not reinsert the . The nurse does not reinsert the
chest tube. The health care provider will reinsert the chest tube as necessary chest tube. The health care provider will reinsert the chest tube as necessary. .
T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination, noting the strategic word “immediate.” Use the process of elimination, noting the strategic word “immediate.”
Eliminate the option that involves reinsertion of the chest tube first because a nurse does not Eliminate the option that involves reinsertion of the chest tube first because a nurse does not
have the required education to insert a chest tube. T have the required education to insert a chest tube. To select from the remaining options, focus o select from the remaining options, focus
on the subject, dislodgment of a chest tube from its insertion site, and recall the complications 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 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 actions to be taken immediately in the event of complications associated with a closed chest
tube drainage system if you had dif tube drainage system if you had difficulty with this question. ficulty with this question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
5.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody ID: 18630136407
secretions. The nurse should take which action first?
6.A. Continue suctioning to remove the blood.
B. Check the degree of suction being applied. C Co or rr re ec ct t
Rationale: Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, 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 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 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 apply intermittent suction and perform catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the mouth will result in increased trauma 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 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 expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody
secretions. secretions.
T Test-T est-Taking Strategy: aking Strategy: Use knowledge of the subject, the technique for nasopharyngeal Use knowledge of the subject, the technique for nasopharyngeal
suctioning. Eliminate the options of continuing the suctioning to remove the blood and removing suctioning. Eliminate the options of continuing the suctioning to remove the blood and removing
the suction catheter from the nose to begin vigorous suctioning through the mouth, because the suction catheter from the nose to begin vigorous suctioning through the mouth, because
they are comparable or alike. Next eliminate the option that involves encouraging the client to they are comparable or alike. Next eliminate the option that involves encouraging the client to
cough out the bloody secretions because it is unlikely that the client will be able to do so. cough out the bloody secretions because it is unlikely that the client will be able to do so.
Review the nursing actions to be taken immediately in the event of a complication during Review the nursing actions to be taken immediately in the event of a complication during
suctioning if you had dif suctioning if you had difficulty with this question. ficulty with this question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory
C. Encourage the client to cough out the bloody secretions.
D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth.
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client ID: 18630135741
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 take which action first?
A. Call a code.
B. Contact the health care provider.
C. Administer a bronchodilator.
D. Disconnect the suction source from the catheter. C Co or rr re ec ct t
7.Rationale: Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the Inability to remove a suction catheter is a critical situation. This finding, along with the
client’ client’s symptoms presented in the question, indicates the presence of bronchospasm and s symptoms presented in the question, indicates the presence of bronchospasm and
bronchoconstriction. The nurse immediately disconnects the suction source from the catheter bronchoconstriction. The nurse immediately disconnects the suction source from the catheter
but leaves the catheter in the trachea. The nurse then connects the oxygen source to the but leaves the catheter in the trachea. The nurse then connects the oxygen source to the
catheter catheter. The health care provider is notified and will most likely prescribe an inhaled . The health care provider is notified and will most likely prescribe an inhaled
bronchodilator bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not . The nurse also prepares for emergency resuscitation if the bronchospasm is not
relieved. relieved.
T Test-T est-Taking Strategy: aking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate Use the process of elimination, noting the strategic word “first.” Eliminate
the option of administering a bronchodilator because this action requires a health care provider the option of administering a bronchodilator because this action requires a health care provider’’s s
prescription. T prescription. To select from the remaining options, visualize the situation presented in the o select from the remaining options, visualize the situation presented in the
question. Noting that the nurse is unable to remove the suction catheter from the client’ question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea s trachea
will direct you to the correct option. Review the nursing actions to be taken immediately in the will direct you to the correct option. Review the nursing actions to be taken immediately in the
event of a complication during suctioning if you had dif event of a complication during suctioning if you had difficulty with this question. ficulty with this question.
Level of Cognitive Ability: Level of Cognitive Ability: Applying Applying
Client Needs: Client Needs: Physiological Integrity Physiological Integrity
Integrated Process: Integrated Process: Nursing Process/Implementation Nursing Process/Implementation
Content Area: Content Area: Adult Health/Respiratory Adult Health/Respiratory
A Awarded 1.0 points out of 1.0 possible points. warded 1.0 points out of 1.0 possible points.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy ID: 18630135753
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first
performs which action?
A. Contacts the health care provider
B. Checks for kinks in the drainage system [Show Less]