MONITORING FOR HEALTH PROBLEMS
Monitoring for Health Problems
Question 1
pts
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?
Contact the health care provider
Place the client in a supine position with the legs flat
Document the findings
Correct!
Cover the abdominal wound with a sterile dressing moistened with sterile saline solution
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.
Question 2
pts
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?
Obtain a flashlight, gauze, and a curved hemostat
Check the client’s blood pressure
Continue the assessment
Correct!
Notify the surgeon
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.
,Question 3
pts
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?
Ensuring that the intravenous (IV) line is patent
Attaching the client to a cardiac monitor
Correct!
Administering oxygen by way of nasal cannula
Preparing the client for a perfusion scan
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.
Question 4
pts
, 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).
Chang the drainage system
Reduce the degree of suction being applied
Clamp the chest tube
Correct!
Document assessment findings, actions taken, and client response
Correct!
Assess the system for an external air leak
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:
Monitoring for Health Problems
Question 1
pts
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?
Contact the health care provider
Place the client in a supine position with the legs flat
Document the findings
Correct!
Cover the abdominal wound with a sterile dressing moistened with sterile saline solution
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.
Question 2
pts
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?
Obtain a flashlight, gauze, and a curved hemostat
Check the client’s blood pressure
Continue the assessment
Correct!
Notify the surgeon
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.
,Question 3
pts
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?
Ensuring that the intravenous (IV) line is patent
Attaching the client to a cardiac monitor
Correct!
Administering oxygen by way of nasal cannula
Preparing the client for a perfusion scan
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.
Question 4
pts
, 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).
Chang the drainage system
Reduce the degree of suction being applied
Clamp the chest tube
Correct!
Document assessment findings, actions taken, and client response
Correct!
Assess the system for an external air leak
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:
