HESI Review Advanced Medical-Surgical Nursing (Miami Dade College): 100 Questions and Answers with Rationale. Includes Test-Taking Strategy, Level of Cognitive Ability, Client Needs, Integrated Proces...
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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 Incorrect 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
Level of Cognitive Ability: Applying Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care
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 Correct Continue the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
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 Correct
Ensuring that the intravenous (IV) line is patent
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 680). St. Louis: Saunders.
. 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 Changing the drainage system
Assessing the system for an external air leak Correct Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response Correct
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 Correct
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 Correct 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