8482572285A 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 dehiscen
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8482572285A 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:
*Covers 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 physician is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.
2. ID: 8482572275A 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 Correct
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.
3. ID: 8482570090A 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:
*Administering oxygen by way of nasal cannula Correct
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 determinations drawn. The immediate priority, however, is the administration of oxygen.
4. ID: 8482572237A 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 Correct
*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.
5. ID: 8482572257A 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:
*Covering the insertion site with a sterile occlusive dressing Correct
Rationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers the site with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps the client back into bed, and contacts the physician. The nurse does not reinsert the chest tube. The physician will reinsert the chest tube as necessary.
6. ID: 8482568053A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. The nurse would first:
*Check the degree of suction being applied Correct
Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning.
Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions.
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7. ID: 8482568077A 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 first:
Disconnect the suction source from the catheter Correct
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the client’s symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse immediately disconnects the suction source
from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
8. ID: 8482572225A 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:
*Checks for kinks in the drainage system Correct
Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest drainage system. The nurse also observes the client for signs of respiratory distress or mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A specific procedure is followed when a new drainage system is connected to a client’s chest tube.
9. ID: 8482572259A 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 first:
Checks the client’s overall intake and output record Correct
Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a 250-mL bolus of normal saline (0.9%) would be implemented without a prescription from the physician. The physician is called once the nurse has gathered all necessary assessment data, including the overall fluid status and vital signs.
10. ID: 8482572277A 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 of the following actions should the nurse take first?
Lowering the head of the bed slowly until the dizziness is relieved Correct
Rationale: Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken.
11. ID: 8482570020A 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. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first?
Placing the client in a modified Trendelenburg position Correct
Rationale: The client is exhibiting signs of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure. The nurse calls the physician, verifies the client’s blood volume status by assessing urine output, and ensures that the IV infusion is proceeding without complications.
12. ID: 8482570082A 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, the nurse should first assess:
The chest tube connections Correct
Rationale: The client’s dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client’s symptoms should resolve.
13. ID: 8482568063A 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 Correct
Rationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in vitamin C. Meats are high in protein. Dairy products are high in calcium.
14. ID: 8482570069A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The physician 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 Correct
Rationale: Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nurse checks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort.
15. ID: 8482568047A client in the postanesthesia care unit has an as-needed
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