Module 9 End Term Exam
Module 9 End Term Exam 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.
, Module 9 End Term Exam
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
A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which
occurrence would prompt the nurse to administer this medication to the client? - ✔Nausea and
vomiting
Module 9 End Term Exam 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.
, Module 9 End Term Exam
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
A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which
occurrence would prompt the nurse to administer this medication to the client? - ✔Nausea and
vomiting
