Exam (elaborations)

ATI MED SURG 2023 QUESTIONS AND ANSWERS WITH Rationale

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Course
Med surg hesi

Institution
Med Surg Hesi

MED SURG HESI REVIEW 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS (Rationale available) 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...

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Uploaded on September 14, 2023
Number of pages 59
Written in 2023/2024
Type Exam (elaborations)
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MED SURG HESI REVIEW 2023
QUESTIONS AND ANSWERS WITH
EXPLANATIONS (Rationale
available)

, rial

MED SURG HESI REVIEW 2023 QUESTIONS AND ANSWERS WITH EXPLANATIONS
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
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

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.

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.

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
Continue the assessment
Check the client’s blood pressure
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: 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.

, rial

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

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.

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.

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
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response

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.

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,

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Exam (elaborations)

ATI MED SURG 2023 QUESTIONS AND ANSWERS WITH Rationale

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