NSG 221
Mental Health Nursing
Pre- Assessment Version 1
Questions & Answers
2025
1.ID: 9477047208
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?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover 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 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
, Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9477054249
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?
A. Notify the surgeon Correct
B. Continue the assessment
C. Check the client’s blood pressure
D. 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: 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:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
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?
A. Preparing the client for a perfusion scan
, B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula Correct
D. 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
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). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 552). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
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).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and client
response Correct
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
, 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). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
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?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover the insertion site with a sterile occlusive dressing Correct
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
Mental Health Nursing
Pre- Assessment Version 1
Questions & Answers
2025
1.ID: 9477047208
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?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover 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 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
, Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9477054249
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?
A. Notify the surgeon Correct
B. Continue the assessment
C. Check the client’s blood pressure
D. 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: 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:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
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?
A. Preparing the client for a perfusion scan
, B. Attaching the client to a cardiac monitor
C. Administering oxygen by way of nasal cannula Correct
D. 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
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). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 552). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
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).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak Correct
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and client
response Correct
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
, 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). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
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?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover the insertion site with a sterile occlusive dressing Correct
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
