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
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
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.
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
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.
,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.
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).
Clamping the chest tube
Changing the drainage system
Assessing the system for an external air leak
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
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 physician 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: Use the process of elimination and your knowledge regarding the priority
actions in the care of a closed chest tube drainage system. Focus on the data in the question,
,noting that there is bubbling in the water seal chamber. 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 if you had difficulty
with this question.
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. The immediate priority on the part of the nurse is:
Contacting the physician
Reinserting the chest tube
Transferring the client back to bed
Covering the insertion site with a sterile occlusive dressing
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 physician. The nurse does not reinsert the chest tube. The
physician will reinsert the chest tube as necessary.
Test-Taking Strategy: Use the process of elimination, noting 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. Review the nursing actions to be taken
immediately in the event of complications associated with a closed chest tube drainage system
if you had difficulty with this question.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth
Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs,
the nurse should first assess the client and then determine the degree of suction being applied.
The degree of suction pressure may need to be decreased. The nurse must also remember to
apply intermittent suction and perform catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the mouth will result in increased trauma
and therefore increased bleeding. Suctioning is normally performed on clients who are unable to
expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody
secretions.
, Test-Taking Strategy: Use the process of elimination. Eliminate the options of continuing the
suctioning to remove the blood and removing the suction catheter from the nose to begin
vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate
the option that involves encouraging the client to cough out the bloody secretions, because it is
unlikely that the client will be able to do so. Review the nursing actions to be taken immediately
in the event of a complication during suctioning if you had difficulty with this question.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
Contact the physician
Administer a bronchodilator
Disconnect the suction source from the catheter
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the
client’s symptoms presented in the question, indicates the presence of bronchospasm and
bronchoconstriction. The nurse immediately disconnects the suction source from the catheter
but leave the catheter in the trachea. The nurse then connects the oxygen source to the
catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The
nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate
the option of administering a bronchodilator, because this action requires a physician’s
prescription. To select from the remaining options, visualize the situation presented in the
question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea
will direct you to the correct option. Review the nursing actions to be taken immediately in the
event of a complication during suctioning if you had difficulty with this question.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
The nurse first:
Contacts the physician
Checks for kinks in the drainage system
Checks the client’s blood pressure and heart rate
Connects a new drainage system to the client’s chest tube
Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest
drainage system. The nurse also observes the client for signs of respiratory distress or
mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate
and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new
drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A
specific procedure is followed when a new drainage system is connected to a client’s chest
tube.
“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
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
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.
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
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.
,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.
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).
Clamping the chest tube
Changing the drainage system
Assessing the system for an external air leak
Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
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 physician 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: Use the process of elimination and your knowledge regarding the priority
actions in the care of a closed chest tube drainage system. Focus on the data in the question,
,noting that there is bubbling in the water seal chamber. 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 if you had difficulty
with this question.
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. The immediate priority on the part of the nurse is:
Contacting the physician
Reinserting the chest tube
Transferring the client back to bed
Covering the insertion site with a sterile occlusive dressing
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 physician. The nurse does not reinsert the chest tube. The
physician will reinsert the chest tube as necessary.
Test-Taking Strategy: Use the process of elimination, noting 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. Review the nursing actions to be taken
immediately in the event of complications associated with a closed chest tube drainage system
if you had difficulty with this question.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied
Encourage the client to cough out the bloody secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through the
mouth
Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs,
the nurse should first assess the client and then determine the degree of suction being applied.
The degree of suction pressure may need to be decreased. The nurse must also remember to
apply intermittent suction and perform catheter rotation during suctioning. Continuing the
suctioning or performing vigorous suctioning through the mouth will result in increased trauma
and therefore increased bleeding. Suctioning is normally performed on clients who are unable to
expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody
secretions.
, Test-Taking Strategy: Use the process of elimination. Eliminate the options of continuing the
suctioning to remove the blood and removing the suction catheter from the nose to begin
vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate
the option that involves encouraging the client to cough out the bloody secretions, because it is
unlikely that the client will be able to do so. Review the nursing actions to be taken immediately
in the event of a complication during suctioning if you had difficulty with this question.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
Contact the physician
Administer a bronchodilator
Disconnect the suction source from the catheter
Rationale: Inability to remove a suction catheter is a critical situation. This finding, along with the
client’s symptoms presented in the question, indicates the presence of bronchospasm and
bronchoconstriction. The nurse immediately disconnects the suction source from the catheter
but leave the catheter in the trachea. The nurse then connects the oxygen source to the
catheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. The
nurse also prepares for emergency resuscitation if the bronchospasm is not relieved.
Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminate
the option of administering a bronchodilator, because this action requires a physician’s
prescription. To select from the remaining options, visualize the situation presented in the
question. Noting that the nurse is unable to remove the suction catheter from the client’s trachea
will direct you to the correct option. Review the nursing actions to be taken immediately in the
event of a complication during suctioning if you had difficulty with this question.
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy
24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
The nurse first:
Contacts the physician
Checks for kinks in the drainage system
Checks the client’s blood pressure and heart rate
Connects a new drainage system to the client’s chest tube
Rationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chest
drainage system. The nurse also observes the client for signs of respiratory distress or
mediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rate
and blood pressure is not directly related to the lack of chest tube drainage. Connecting a new
drainage system to the client’s chest tube is done once the fluid drainage chamber is full. A
specific procedure is followed when a new drainage system is connected to a client’s chest
tube.
