1. Questions
A client reports for a scheduled electroencephalogram
(EEG). Which statement by the client indicates a need for
additional preparation for the test?
A. “I didn’t shampoo my hair.” Correct
B. “I ate br
...
1. Questions
A client reports for a scheduled electroencephalogram
(EEG). Which statement by the client indicates a need for
additional preparation for the test?
A. “I didn’t shampoo my hair.” Correct
B. “I ate breakfast this morning.”
C. “I didn’t take my anticonvulsant today.”
D. “It was hard not to drink coffee this morning, but
I knew that I couldn’t, so I didn’t.”
Awarded 1.0 points out of 1.0 possible points.
HESI Concepts: Teaching and Learning/Patient Education, Intracranial
Regulation
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., pp. 922-923). St. Louis: Saunders.
A+
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
A+
C. Check the client’s blood pressure
D. Obtain a flashlight, gauze, and a curved
hemostat
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9477051455
A client who has just undergone surgery suddenly
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
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
A+
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
A+
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9477051498
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).
A. Clamp the chest tube
B. Chang the drainage system
C. Assess the system for an external air leak
Correct
prioritizing. Use 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
Level of Cognitive Ability: Applying
Client Needs: Physiologic
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