MMODULE 9 EXAM COMPLETE
DETAILED CASE STUDY
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? - 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? - 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? -
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. - 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? - 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? - 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? - 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? - 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? -
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? - 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? - 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? -
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? -
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? - Suction equipment
DETAILED CASE STUDY
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? - 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? - 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? -
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. - 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? - 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? - 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? - 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? - 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? -
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? - 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? - 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? -
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? -
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? - Suction equipment
