NURSING 428 Module 9 Exam. Questions with Answers. Nicholls State University.ID: 8482572285A client who has undergone abdominal surgery calls the nurse
... [Show More] 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:
*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.
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
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.
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:
*Administering oxygen by way of nasal cannula Correct
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.
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).
*Assessing the system for an external air leak Correct
*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.
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:
*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 [Show Less]