HESI Extra Credit exam Module 9
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HESI
Extra
Credit
exam
Module 9
Exam
with
,HESI Extra Credit exam Module 9
Exam withrationale
rationale
, HESI Extra Credit exam Module 9 Exam with
rationale
1. Questions
1. 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
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Caregiving, Tissue Integrity
HESI Concepts: Caregiving, Tissue 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
, HESI Extra Credit exam Module 9 Exam with
rationale
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
: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
Exam withrationale
HESI
Extra
Credit
exam
Module 9
Exam
with
,HESI Extra Credit exam Module 9
Exam withrationale
rationale
, HESI Extra Credit exam Module 9 Exam with
rationale
1. Questions
1. 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
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Caregiving, Tissue Integrity
HESI Concepts: Caregiving, Tissue 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
, HESI Extra Credit exam Module 9 Exam with
rationale
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
: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
