NURSING NCLEX Module 9 NEW UPDATED PRACTICE EXAM QUESTIONS AND ANSWERS ALL SOLVED SOLUTION Carrington College 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 docum ents the occurrence and the nursing actions that were implemented in response. TestTaking 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 Proce ss/Implementation Content Area: Perioperative Care 1. Questions 1. 1. 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 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 1. Rationale: Wound dehisQuestions 1. 1. 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 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: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If the client vomits a large amount of brightred blood or the pulse rate increases and the patient is restless, the nurse must notify the surgeon immediately. The nurse should o btain 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. TestTaking Strategy: Note the strategic word, immediate. Noting the words “brightred blood” will assist in directing you to the correct option. Remember that the presence of brightred 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, PerfusionClotting Reference: Ignatavicius, D., & Workman, M. (2013). Medicalsurgical nursing: Patientcentered collaborative care. (7th ed., p. 644). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 2. 2. 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 conti nues the assessment, the client begins to vomit a copious amount of brightred blood. The nurse should take which immediate action? A. Notify the surgeon Correct B. Continue the assessment C. Check the client’s blood pressure D. Obtain a flashlight, gauze, and a curved hemostat Awarded 1.0 points out of 1.0 possible points. 3. 3. 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 Giddens Concepts: Caregiving, Tissue Integrity HESI Concepts: Caregiving, Tissue Integrity Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby. 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, Rationale: Pulmonary embolism is a lifethreatening 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. TestTaking Strategy: Focus on the client’s diagnosis and use the skills of 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, PerfusionClotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby. 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 Awarded 1.0 points out of 1.0 possible points. 4. 4. 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
