Hesi medical surgical final exit exam 2 2023

lOMoAR cPSD| 2876922




HESIMEDICALSURGICALFINALEXITEXAM2 l l l l l l




-2023
• A client who just returned from the recovery room after a tonsillectomyand
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adenoidectomy is restless and her pulse rate is increased. As the nurse conti l l l l l l l l l l l l



nues the assessment, the client begins to vomit a copious amount of bright-
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red blood. The immediate nursing action is to:
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Notify the surgeonCont l l l




inue the assessment l l




Check the client’s blood pressure l l l l




Obtain a flashlight, gauze, and a curved hemostat l l l l l l l




Rationale: Hemorrhage is a potential complication after tonsillectomy andade
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noidectomy. If the client vomits a large amount of bright- l l l l l l l l l



red blood orthe pulse rate increases and the patient is restless, the nurse must
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notify the surgeonimmediately. The nurse should obtain a light, mirror, gauze, c
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urved hemostat, andwaste basin to facilitate examination of the surgical site. T
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he nurse should also gather additional assessment data, but the surgeon must
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be contacted immediately.
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Test-
Taking Strategy: Focus on the data in the question. Noting the words“bright-
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red blood” will assist in directing you to the correct option.
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Remember that the presence of bright- l l l l l



red blood indicates active bleeding. Review the nursing actionsto be taken im
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mediately when bleeding occurs after a tonsillectomy and adenoidectomy if
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you haddifficulty with this question.
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,LevelofCognitiveAbility:
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Applying Client Needs: l l




Physiological Integrity l




Integrated Process: Nursing Process/ Impleme l l l l




ntationContent Area: Delegating/Prioritizing l l l




Reference: Ignatavicius, D., & Workman, M. (2010). Medical-
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surgicalnursing: Patient-centered collaborative care (6th ed., p. 657). St.
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Louis:Saunders.



• A client who has just undergone surgery suddenly experiencesche
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st pain, dyspnea, and tachypnea. The nurse suspects that the client has
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apulmonary embolism and immediately sets about: l l l l l




Preparing the client for a perfusion scan Atta l l l l l l l




ching the client to a cardiac monitor Adminis
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tering oxygen by way of nasal cannula Ensuri
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ng that the intravenous (IV)line is patent
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Rationale: Pulmonary embolism is a life-threatening emergency. Oxygen is
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immediately administered nasally to relieve hypoxemia, respiratory distre
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ss, and central cyanosis, and the physician is notified. IV infusion
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,lines are needed to administer medications or fluids. A perfusion scan, among o
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ther tests, may be performed. The electrocardiogram is monitored for the pres
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ence of dysrhythmias.Additionally, a urinary cathetermay be inserted and bloo
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d for arterial blood gas determinations drawn.
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The immediate priority, however, is the administration ofoxygen.
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Test-
Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing
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. Apply the ABCs (airway, breathing, and circulation) to find thecorrectoption.
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Review the nursing actions to be taken immediately in theeventof pulmonar
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yembolism if youhad difficulty with thisquestion.
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LevelofCognitiveAbility:l l l




Applying Client Needs: l l




Physiological Integrity l




Integrated Process: Nursing Process/ Impleme l l l l




ntationContent Area: Delegating/Prioritizing l l l




Reference: Ignatavicius, D., & Workman, M. (2010). Medical- l l l l l l l



surgicalnursing: Patient-centered collaborative care (6th ed., p. 680). St.
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Louis:Saunders.

, • A nurse is assessing a client who has a closed chest tube drainage syste
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m. Thenurse notes constant bubbling in the water seal chamber.What acti
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ons should the nurse take? (Select all that apply).
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Clamping the chest tubeChan l l l l




ging the drainage system
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Assessing the system for an external air leak Corr
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ectReducing the degree of suction beingapplied
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