HESI Med Surg Exam
Questions with answers,
Rationales
Test taking Strategies
and References.
,1.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.
Questions with answers,
Rationales
Test taking Strategies
and References.
,1.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.
