NURSING NCLEX Module 9, Monitoring for Health Problems, Exam Questions and Answers

Monitoring for Health Problems Question 1 1 / 1 pts 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? Contact the health care provider Place the client in a supine position with the legs flat Document the findings Correct! Cover 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 health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response. Test-Taking 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 Process/Implementation Content Area: Perioperative Care 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. Question 2 1 / 1 pts 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 continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? Obtain a flashlight, gauze, and a curved hemostat Check the client’s blood pressure Continue the assessment Correct! Notify the surgeon 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: Note the strategic word, immediate. 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 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, Perfusion-Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 644). St. Louis: Saunders.Question 3 1 / 1 pts 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? Ensuring that the intravenous (IV) line is patent Attaching the client to a cardiac monitor Correct! Administering oxygen by way of nasal cannula Preparing the client for a perfusion scan 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 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. Test-Taking 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, Perfusion-Clotting 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. Question 4 1 / 1 ptsA 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). Chang the drainage system Reduce the degree of suction being applied Clamp the chest tube Correct! Document assessment findings, actions taken, and client response Correct! Assess the system for an external air leak 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: Focus on the data in the question, noting that there is bubbling in the water seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube drainage system. 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 Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area:Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Question 5 1 / 1 pts 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. What is the immediate nursing action? Correct! Cover the insertion site with a sterile occlusive dressing Transfer the client back to bed Contact the health care provider Reinsert the chest tube 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: Note the strategic word “immediate.” Eliminate the option that involves reinsertion of the chest tube first, because a nurse is not trained 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 Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area:Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby.