NEW GENERATION ATI COMPREHENSIVE HESI MEDICAL SURGICAL ASSESSMENT | REAL FINAL EXAM

NEW GENERATION ATI COMPREHENSIVE HESI MEDICAL SURGICAL ASSESSMENT | REAL FINAL EXAM 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 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. 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. 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. NEW GENERATION ATI COMPREHENSIVE HESI MEDICAL SURGICAL ASSESSMENT | REAL FINAL EXAM • 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,