1. Module 9 Exam - felt “something give way” in the abdominal ...

• Module 9 Exam

1.1.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?

• Document the findings
• Contact the primary health care provider
• Place the client in a supine position with the legs flat
• Cover the abdominal wound with a sterile dressing moistened with

sterile saline solution 2.2.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?

• Notify the surgeon
• Continue the assessment
• Check the client’s blood pressure
• Obtain a flashlight, gauze, and a curved hemostat

3.3.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?

• 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

4.4.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.

• Clamp the chest tube
• Change the drainage system
• Assess the system for an external air leak
• Reduce the degree of suction being applied
• Document assessment findings, actions taken, and client response

5.5.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?

• Reinsert the chest tube

• Contact the primary health care provider
• Transfer the client back to bed
• Cover the insertion site with a sterile occlusive dressing

6.6.A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first?

• Continue suctioning to remove the blood
• Check the degree of suction being applied
• Encourage the client to cough out the bloody secretions
• Remove the suction catheter from the client’s nose and begin

vigorous suctioning through the mouth 7.7.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. Which action should the nurse take first?

• Call a code
• Contact the primary health care provider
• Administer a bronchodilator
• Disconnect the suction source from the catheter

8.8.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. Which action should the nurse take first?

• Contact the primary health care provider
• Check for kinks in the drainage system
• Check the client’s blood pressure and heart rate
• Connect a new drainage system to the client’s chest tube

9.9.A nurse is assessing 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 should take which action first?

• Call the primary health care provider
• Increase the rate of the IV infusion
• Check the client’s overall intake and output record
• Administer a 250-mL bolus of normal saline solution (0.9%)

10.10.

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?

• Check the client’s blood pressure
• Check the oxygen saturation level
• Have the client take some deep breaths

• Lower the head of the bed slowly until the dizziness is relieved

11.11.

A nurse is preparing for intershift report when an assistive personnel (AP) 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.The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first?

• Call the primary health care provider
• Check the hourly urine output
• Check the IV site for infiltration
• Place the client in a modified Trendelenburg position

12.12.

A nurse is assessing 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, what should the nurse assess first?

• The client’s vital signs
• The amount of drainage
• The client’s lung sounds
• The chest tube connections

13.13.

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?

• Steak
• Veal
• Cheese
• Oranges

14.14.

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The primary health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink?

• Straw
• Napkin
• Suction equipment
• Oxygen saturation monitor

15.15.

A client in the post-anesthesia care unit has an as-needed prescription for ondansetron.Which occurrence would prompt the nurse to administer this medication to the client?

• Paralytic ileus
• Incisional pain

• Urine retention
• Nausea and vomiting

16.16.

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client?

• Pupil constriction
• Increased urine output
• Complaints of dry mouth
• Complaints of feeling sweaty

17.17.

A nurse is preparing a client for transfer to the operating room. Which action should the nurse take in the care of this client at this time?

• Ensuring that the client has voided
• Administering all daily medications
• Practicing postoperative breathing exercises
• Verifying that the client has not eaten for the last 24 hours

18.18.

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client?

• Assess the patency of the airway
• Check tubes and drains for patency
• Check the dressing for bleeding
• Assess the vital signs to compare them with preoperative

measurements

19.19.

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value?

A. 85%

B. 89%

C. 95%

D. 100%

20.20.

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

• Hematocrit 30% (0.30)
• Sodium 141 mEq/L (141 mmol/L)
• Hemoglobin 8.9 g/dL (89 g/L)
• Platelets 210× 103/μL (210 × 109/L)
• Serum creatinine 0.8 mg/dL (70 μmol/L)

21.21.