1. Questions
1. 1.ID: 9477047208
A client who has undergone abdominal surgery calls the nurse and reports that
she just felt “something give way”
... [Show More] in the abdominal incision. The nurse checks
the incision and notes the presence of wound dehiscence. The nurse should
take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover 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 health care provider is notified, and the nurse documents the
occurrence and the nursing actions that were implemented in response.
Test-Taking Strategy: Note the strategic word “immediate.” 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Caregiving, Tissue Integrity
HESI Concepts: Caregiving, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 180). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9477054249
A client who just returned from the recovery room after a tonsillectomy and
adenoidectomy is restless and the pulse rate is increased. As the nurse
continues the assessment, the client begins to vomit a copious amount of
bright-red blood. The nurse should take which immediate action?
A. Notify the surgeon Correct
B. Continue the assessment
Extra Credit HESI Module 9
C. Check the client’s blood pressure
D. 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: Note the strategic word, immediate. 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Collaboration, Clotting
HESI Concepts: Collaboration/Managing Care, Perfusion-Clotting
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
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 to take 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 Correct
D. 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
health care provideris 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
Extra Credit HESI Module 9
prioritizing. Use 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 552). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
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).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document 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 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 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: Focus on the data in the question, noting that there is
bubbling in the water seal chamber. Use knowledge regarding the priority
actions in the care of a closed chest tube drainage system. Recalling that this
may indicate an air leak will direct you to the correct options. Review the
Extra Credit HESI Module 9
nursing actions to be taken immediately in the event that complications of a
closed chest tube drainage system occur
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
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. What is the immediate nursing
action?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover 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 health care provider. The nurse does not reinsert the chest tube. The health
care provider
will reinsert the chest tube as necessary.
Test-Taking Strategy: Note 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
Giddens Concepts: Care Coordination, Gas Exchange
Extra Credit HESI Module 9
HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 9477047967
A nurse performing nasopharyngeal suctioning and suddenly notes the
presence of bloody secretions. Which action should the nurse take first?
A. Continue suctioning to remove the blood
B. Check the degree of suction being applied Correct
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
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: Note the strategic word, first. 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 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. Review the nursing actions to be taken
immediately in the event of a complication during suctioning
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
Giddens Concepts: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas
Exchange
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 629, 635). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 9477054269
Extra Credit HESI Module 9
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. Which action should the nurse take first?
A. Call a code
B. Contact the health care provider
C. Administer a bronchodilator
D. Disconnect the suction source from the catheter Correct
Rationale: Inability to remove a suction catheter is a critical situation. This
finding, along with the client’s symptoms presented in the question, indicates
the presence of bronchospasm and bronchoconstriction. The nurse
immediately disconnects the suction source from the catheter but leave the
catheter in the trachea. The nurse then connects the oxygen source to the
catheter. The health care provider is notified and will most likely prescribe an
inhaled bronchodilator. The nurse also prepares for emergency resuscitation if
the bronchospasm is not relieved.
Test-Taking Strategy: Note the strategic word “first.” Eliminate the option of
administering a bronchodilator, because this action requires a health care
provider’s prescription. To 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’s trachea will direct you to the correct
option. Review the nursing actions to be taken immediately in the event of a
complication during suctioning
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
Giddens Concepts: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas
Exchange
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., pp. 574-575). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 9477044479
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.
Which action should the nurse take first?
A. Contact the health care provider
B. Check for kinks in the drainage system Correct
C. Check the client’s blood pressure and heart rate
Extra Credit HESI Module 9
D. Connect a new drainage system to the client’s chest tube
Rationale: If a chest tube is not draining, the nurse must first check for a kink or
clot in the chest drainage system. The nurse also observes the client for signs
of respiratory distress or mediastinal shift; and if such signs are noted, the
health care provider is notified. Checking the heart rate and blood pressure is
not directly related to the lack of chest tube drainage. Connecting a new
drainage system to the client’s chest tube is done once the fluid drainage
chamber is full. A specific procedure is followed when a new drainage system is
connected to a client’s chest tube.
Test-Taking Strategy: Note strategic word “first.” Focusing on the subject, a lack
of chest tube drainage, will direct you to the correct option. Review unexpected
outcomes and related interventions in the care of a chest tube drainage system
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
Giddens Concepts: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas
Exchange
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 637). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 9477047216
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 should take which action first?
A. Call the health care provider
B. Increase the rate of the IV infusion
C. Check the client’s overall intake and output record Correct
D. Administer a 250-mL bolus of normal saline solution (0.9%)
Rationale: Clients are at risk for becoming hypovolemic after surgery, and often
the first sign of hypovolemia is decreasing urine output. However, the nurse
needs additional data to make an accurate interpretation. Neither an increase
in the rate of the IV infusion nor administration of a 250-mL bolus of normal
saline (0.9%) would be implemented without a prescription from the health care
provider. The health care provider is called once the nurse has gathered all
necessary assessment data, including the overall fluid status and vital signs.
Test-Taking Strategy: Note the strategic word “first.” Try to visualize the
situation and use the steps of the nursing process to answer the question. The
correct option addresses the process of assessment. Eliminate increasing the
rate of the IV infusion and administering a 250-mL bolus of normal saline
Extra Credit HESI Module 9
(0.9%), because each requires a health care provider’s prescription. In this
situation, the nurse needs to gather additional information before contacting the
health care provider. Review unexpected outcomes after surgery and priority
nursing interventions in the event of such outcomes
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Clinical Judgment, Elimination
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., pp. 289-290). St. Louis: Saunders. [Show Less]