MODULE 9 EXAM EFCT
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 takes
which action? - answer-Covers the abdominal wound with a sterile dressing
moistened with sterile saline solution
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.
Which is the immediate nursing action? - answer-Notify the surgeon
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 takes which action? - answer-Administering oxygen by way of nasal
cannula
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. - answer-Assessing the system for an external air
leak
Documenting assessment findings, actions taken, and client response
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 which action? - answer-Covering the insertion site with a sterile occlusive
dressing
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of
bloody secretions. The nurse should take which action first? - answer-Check the
degree of suction being applied.
A nurse is suctioning a client through a tracheostomy tube. During the procedure,
the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove
the suction catheter from the client's trachea but is unable to do so. The nurse
would take which action first? - answer-Disconnect the suction source from the
catheter.
A nurse assesses the closed chest tube drainage system of a client who underwent
lobectomy 24 hours ago. The nurse notes that there has been no chest tube
drainage for the past hour. The nurse first performs which action? - answer-Checks
for kinks in the drainage system
A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that
the client's urine output for the past hour was 25 mL. On the basis of this finding,
, the nurse takes which action first? - answer-Checks the client's overall intake and
output record
A nurse is getting a client out of bed for the first time since surgery. The nurse
raises the head of the bed, and the client complains of dizziness. Which action
should the nurse take first? - answer-Lowering the head of the bed slowly until the
dizziness is relieved
A nurse is preparing for intershift report when a nurse's aide pulls an emergency
call light in a client's room. Upon answering the light, the nurse finds a client who
returned from surgery earlier in the day experiencing tachycardia and tachypnea.
Which action should the nurse take first? - answer-Administering oxygen at the
prescribed rate
A nurse is monitoring the chest tube drainage system of a postoperative client who
has undergone a right upper lobectomy. The closed drainage system contains 300
mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal
chamber. One hour after the initial assessment, the nurse notes that the bubbling in
the water seal chamber is now constant, and the client appears dyspneic. On the
basis of these findings, the nurse should assist with data collection by examining
which aspect first? - answer-The chest tube connections
A client recovering from surgery has a large abdominal wound. Which of the
following foods, high in vitamin C, should the nurse encourage the client to eat as a
means of promoting wound healing? - answer-Oranges
A nurse is caring for a client who has just regained bowel sounds after undergoing
surgery. The health care provider has prescribed a clear liquid diet for the client.
Which of the following items does the nurse ensure is available in the client's room
before allowing the client to drink? - answer-Suction equipment
A client in the postanesthesia care unit has an as-needed prescription for
ondansetron. Which occurrence would prompt the nurse to administer this
medication to the client? - answer-Nausea and vomiting
A nurse administers scopolamine as prescribed to a client in preparation for
surgery. For which side effect of this medication does the nurse monitor the client? -
answer-Complaints of dry mouth
A nurse is preparing a client for transfer to the operating room. Which action should
the take in the care of this client at this time? - answer-Ensuring that the client has
voided
A nurse receives a telephone call from a nurse on the post-anesthesia care unit,
who reports that a client is being transferred to the surgical unit. What should the
nurse plan to do first on arrival of the client? - answer-Assess the patency of the
airway
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 takes
which action? - answer-Covers the abdominal wound with a sterile dressing
moistened with sterile saline solution
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.
Which is the immediate nursing action? - answer-Notify the surgeon
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 takes which action? - answer-Administering oxygen by way of nasal
cannula
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. - answer-Assessing the system for an external air
leak
Documenting assessment findings, actions taken, and client response
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 which action? - answer-Covering the insertion site with a sterile occlusive
dressing
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of
bloody secretions. The nurse should take which action first? - answer-Check the
degree of suction being applied.
A nurse is suctioning a client through a tracheostomy tube. During the procedure,
the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove
the suction catheter from the client's trachea but is unable to do so. The nurse
would take which action first? - answer-Disconnect the suction source from the
catheter.
A nurse assesses the closed chest tube drainage system of a client who underwent
lobectomy 24 hours ago. The nurse notes that there has been no chest tube
drainage for the past hour. The nurse first performs which action? - answer-Checks
for kinks in the drainage system
A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that
the client's urine output for the past hour was 25 mL. On the basis of this finding,
, the nurse takes which action first? - answer-Checks the client's overall intake and
output record
A nurse is getting a client out of bed for the first time since surgery. The nurse
raises the head of the bed, and the client complains of dizziness. Which action
should the nurse take first? - answer-Lowering the head of the bed slowly until the
dizziness is relieved
A nurse is preparing for intershift report when a nurse's aide pulls an emergency
call light in a client's room. Upon answering the light, the nurse finds a client who
returned from surgery earlier in the day experiencing tachycardia and tachypnea.
Which action should the nurse take first? - answer-Administering oxygen at the
prescribed rate
A nurse is monitoring the chest tube drainage system of a postoperative client who
has undergone a right upper lobectomy. The closed drainage system contains 300
mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal
chamber. One hour after the initial assessment, the nurse notes that the bubbling in
the water seal chamber is now constant, and the client appears dyspneic. On the
basis of these findings, the nurse should assist with data collection by examining
which aspect first? - answer-The chest tube connections
A client recovering from surgery has a large abdominal wound. Which of the
following foods, high in vitamin C, should the nurse encourage the client to eat as a
means of promoting wound healing? - answer-Oranges
A nurse is caring for a client who has just regained bowel sounds after undergoing
surgery. The health care provider has prescribed a clear liquid diet for the client.
Which of the following items does the nurse ensure is available in the client's room
before allowing the client to drink? - answer-Suction equipment
A client in the postanesthesia care unit has an as-needed prescription for
ondansetron. Which occurrence would prompt the nurse to administer this
medication to the client? - answer-Nausea and vomiting
A nurse administers scopolamine as prescribed to a client in preparation for
surgery. For which side effect of this medication does the nurse monitor the client? -
answer-Complaints of dry mouth
A nurse is preparing a client for transfer to the operating room. Which action should
the take in the care of this client at this time? - answer-Ensuring that the client has
voided
A nurse receives a telephone call from a nurse on the post-anesthesia care unit,
who reports that a client is being transferred to the surgical unit. What should the
nurse plan to do first on arrival of the client? - answer-Assess the patency of the
airway
