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:

Contacts the physician Incorrect

Documents the findings

Places the client in a supine position with the legs flat

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.

Test-Taking Strategy: Use the process of elimination and note the strategic word

“immediately.” 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 if

you had difficulty with this question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Perioperative Care

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., pp. 291, 292, 296). St. Louis: Saunders.

Awarded 0.0 points out of 1.0 possible points.

2.ID: 383740621

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. The immediate nursing action is to:

Notify the surgeon Correct

Continue the assessment

Check the client’s blood pressure 

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: Focus on the data in the question. 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 if you had difficulty with this

question.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing

Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered

collaborative care (6th ed., p. 657). St. Louis: Saunders.

Awarded 0.0 points out of 1.0 possible points.

3.ID: 383739348

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:

Preparing the client for a perfusion scan

Attaching the client to a cardiac monitor

Administering oxygen by way of nasal cannula Correct

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

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.

Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply 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 if you had difficulty with this

question.