NURSING_1429041 Test Bank (Verified Answers).

NURSING_ Test Bank (Verified Answers). Questions 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 should take which immediate action? o Document the findings o Contact the health care provider o Place the client in a supine position with the legs flat o Cover the abdominal wound with a sterile dressing moistened with sterile saline solution 2. 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? o Notify the surgeon o Continue the assessment o Check the client’s blood pressure o Obtain a flashlight, gauze, and a curved hemostat 3. 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? o Preparing the client for a perfusion scan o Attaching the client to a cardiac monitor o Administering oxygen by way of nasal cannula o Ensuring that the intravenous (IV) line is patent 4. 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). o Clamp the chest tube o Chang the drainage system o Assess the system for an external air leak o Reduce the degree of suction being applied o Document assessment findings, actions taken, and client response 5. 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? o Reinsert the chest tube o Contact the health care provider o Transfer the client back to bed o Cover the insertion site with a sterile occlusive dressing 6.A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? o Continue suctioning to remove the blood o Check the degree of suction being applied o Encourage the client to cough out the bloody secretions o Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth 7.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. Which action should the nurse take first? o Call a code o Contact the health care provider o Administer a bronchodilator o Disconnect the suction source from the catheter 8.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. Which action should the nurse take first? o Contact the health care provider o Check for kinks in the drainage system o Check the client’s blood pressure and heart rate o Connect a new drainage system to the client’s chest tube