HESI EXAM QUESTIONS AND ANSWERS

Questions 1. 1.ID: 8 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 1. Rationale: Wound dehisQuestions 1. 1.ID: 8 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. Test­Taking 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. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9 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 bright­red 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 bright­red 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. Test­Taking Strategy: Note the strategic word, immediate. Noting the words “bright­red blood” will assist in directing you to the correct option. Remember that the presence of bright­red 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, Perfusion­Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 644). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points.