HESI Extra Credit Module 9 Exam Monitoring for Health Problems [NEW!!] 2022 (71 Pages) 100% CORRECT
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Course
HESI
Institution
HESI
A client who has undergone abdominal surgery calls the nurse and reports that she just felt ID: 63
“something give way” in the abdominal incision. The nurse checks the incision and notes the presence of
wound dehiscence. The nurse immediately takes which action?
A. Contacts the health care p...
hesi extra credit module 9 exam monitoring for health problems new 2022 71 pages 100 correct
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Submission Details
Submission Date: 7/31/2021 Number of Attempts Allowed: Unlimited
Submission Time: 8:38 PM Not Scored: 0
Points Awarded: 109 Percentage: 98.2%
Points Missed: 2
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Questions
1. A client who has undergone abdominal surgery calls the nurse and reports that she just felt ID: 18630135763
“something give way” in the abdominal 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 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 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: Use the process of elimination and note the strategic word “immediately.”
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 if you had difficulty with this
question.
,2. 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. 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 data, but the surgeon must be contacted immediately.
Test-Taking Strategy: 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
indicates active bleeding. Review the nursing actions to be taken immediately when bleeding
occurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.
Level of Cognitive Ability: Applying
B. Auscultate the lungs.
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. 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 Correct
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 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
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 prioritizing. Apply 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 if you had difficulty with this
question.
D. Ensuring that the intravenous (IV) line is patent
Awarded 1.0 points out of 1.0 possible points.
4. 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 Correct
D. Reducing the degree of suction being applied
E. 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 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: 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
is bubbling in the water seal chamber. 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
closed chest tube drainage system occur if you had difficulty with this question.
5. 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 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: 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
have the required education 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 if you had difficulty with this question.
6. A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody ID: 18630136407
secretions. The nurse should take which action first?
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