NURSING NCLEX MODULE 9 EXAM.
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 sterilesaline solution
Correct
1. Rationale: Wound dehisQuestions
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 sterilesaline 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
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
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
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 “brightred 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
c tv c . d p d
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 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: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby.
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
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and clientresponse 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 health care provider 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.
Test-Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water
seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube
drainage system. Recalling that this may indicate an air leak will direct you to the correct options.
Review the nursing actions to be taken immediately in the event that complications of a closed chest
tube drainage system occur
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
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?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover 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 health care provider. The nurse does not reinsert the chest tube.
The health care provider
will reinsert the chest tube as necessary.
Test-Taking Strategy: Note the strategic word “immediate.” Eliminate the option that involves
reinsertion of the chest tube first, because a nurse is not trained to insert a chest tube. To select
from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site,
and recall the complications associated with this occurrence; this will direct you to the correct option.
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 sterilesaline solution
Correct
1. Rationale: Wound dehisQuestions
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 sterilesaline 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
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 180). St. Louis: Mosby.
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
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 “brightred 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
c tv c . d p d
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 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: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care: Emergency Situation/Management
Giddens Concepts: Perfusion, Clotting
HESI Concepts: Oxygenation/Gas Exchange, Perfusion-Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby.
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
D. Reduce the degree of suction being applied
E. Document assessment findings, actions taken, and clientresponse 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 health care provider 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.
Test-Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water
seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube
drainage system. Recalling that this may indicate an air leak will direct you to the correct options.
Review the nursing actions to be taken immediately in the event that complications of a closed chest
tube drainage system occur
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area:
Critical Care: Emergency Situation/Management
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing:
Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
5. 5.ID: 9477055619
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?
A. Reinsert the chest tube
B. Contact the health care provider
C. Transfer the client back to bed
D. Cover 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 health care provider. The nurse does not reinsert the chest tube.
The health care provider
will reinsert the chest tube as necessary.
Test-Taking Strategy: Note the strategic word “immediate.” Eliminate the option that involves
reinsertion of the chest tube first, because a nurse is not trained to insert a chest tube. To select
from the remaining options, focus on the subject, dislodgment of a chest tube from its insertion site,
and recall the complications associated with this occurrence; this will direct you to the correct option.
