lOM oA R c P S D| 19 50 098 6
lOM oA R c P S D| 19 50 09
MED SURG 2 HESI TEST BANK REAL EXAM 100+
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
• 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. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
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: Focus on the data in the question. Noting the words “bright-
red blood” will assist in directing you to the correct option. Remember that the
, lOM oA R c P S D| 19 50 098 6
presence of bright-red blood indicates active bleeding. Review the nursing actions
to be taken immediately when bleeding occurs after a tonsillectomy and
adenoidectomy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 657). St. Louis:
Saunders.
• 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:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
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 physician is 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
, lOM oA R c P S D| 19 50 098 6
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. Apply 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 if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 680). St. Louis:
Saunders.
• 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).
Clamping the chest tube
Changing the drainage system
, lOM oA R c P S D| 19 50 098 6
Assessing the system for an external air leak Correct
Reducing the degree of suction being applied
Documenting 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 physician 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: Use the process of elimination and your knowledge regarding
the priority actions in the care of a closed chest tube drainage system. Focus on
the data in the question, noting that there is bubbling in the water seal chamber.
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 if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
lOM oA R c P S D| 19 50 09
MED SURG 2 HESI TEST BANK REAL EXAM 100+
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
• 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. The immediate nursing action is to:
Notify the surgeon
Continue the assessment
Check the client’s blood pressure
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: Focus on the data in the question. Noting the words “bright-
red blood” will assist in directing you to the correct option. Remember that the
, lOM oA R c P S D| 19 50 098 6
presence of bright-red blood indicates active bleeding. Review the nursing actions
to be taken immediately when bleeding occurs after a tonsillectomy and
adenoidectomy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 657). St. Louis:
Saunders.
• 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:
Preparing the client for a perfusion scan
Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
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 physician is 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
, lOM oA R c P S D| 19 50 098 6
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. Apply 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 if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 680). St. Louis:
Saunders.
• 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).
Clamping the chest tube
Changing the drainage system
, lOM oA R c P S D| 19 50 098 6
Assessing the system for an external air leak Correct
Reducing the degree of suction being applied
Documenting 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 physician 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: Use the process of elimination and your knowledge regarding
the priority actions in the care of a closed chest tube drainage system. Focus on
the data in the question, noting that there is bubbling in the water seal chamber.
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 if you had difficulty
with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
