lOM oA R l l
cP S D| 287692 25
• A client who just returned from the recovery room after a tonsillectomy and aden
l l l l l l l l l l l l l
oidectomy is restless and her pulse rate is increased. As the nurse continues the asse
l l l l l l l l l l l l l l
ssment, the client begins to vomit a copious amount of bright-
l l l l l l l l l l
red blood. The immediate nursing action is to:
l l l l l l l l
Notify the surgeon Contin l l l
ue 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 and adenoide
l l l l l l l l l
ctomy. If the client vomits a large amount of bright-
l l l l l l l l l
red blood or the pulse rate increases and the patient is restless, the nurse must notify t
l l l l l l l l l l l l l l l l
he surgeonimmediately. The nurse shouldobtaina light, mirror, gauze, curved hemost
l l l l l l l l l l l l
at, andwaste basin to facilitate examination of the surgical site. The nurse should also
l l l l l l l l l l l l l l l
gather additional assessment data, but the surgeon must be contacted immediately.
l l l l l l l l l l
Test-TakingStrategy:Focus onthe data in the question. Noting thewords“bright-
l l l l l l l l l l l l
red blood” will assist in directing you to the correct option. Remember that the
l l l l l l l l l l l l l l
,presence of bright- l l
red blood indicates active bleeding. Review the nursing actionsto be taken immediate
l l l l l l l l l l l l
ly when bleeding occurs after a tonsillectomy and adenoidectomy if you had difficulty
l l l l l l l l l l l l l
with this question. l l
Level of Cognitive Ability: Applying Clie
l l l l l
ntNeeds: Physiological Integrity
l l l
Integrated Process:Nursing Process/ImplementationC l l l l
ontent Area: Delegating/Prioritizing l l
Reference: Ignatavicius, D., & Workman, M. (2010). Medical- l l l l l l l
surgical nursing:Patient- l l
centered collaborative care (6th ed., p. 657). St. Louis:Saunders.
l l l l l l l l l
• A client who has just undergone surgery suddenly experiences chest pain,dys
l l l l l l l l l l l
pnea, and tachypnea. The nurse suspects that the client has a pulmonary embo
l l l l l l l l l l l l
lism and immediately sets about:
l l l l
Preparing the client for a perfusion scan Attaching t l l l l l l l l
he client to a cardiac monitor Administering oxyge
l l l l l l l
n by way of nasal cannula Ensuring that the intrave
l l l l l l l l l
nous (IV) line is patent l l l l
Rationale:Pulmonaryembolism is a life-threatening emergency. Oxygen is l l l l l l l l
immediately administered nasally to relieve hypoxemia, respiratory distress, and cent l l l l l l l l l
ral cyanosis, and the physician is notified. IV infusion lines are needed to administer me
l l l l l l l l l l l l l l
dications or fluids. A perfusion scan, among other tests, may be performed. The electro
l l l l l l l l l l l l l
cardiogram is monitored for the presence of dysrhythmias.Additionally, a urinary cathe
l l l l l l l l l l l
,ter may be inserted and blood for arterial blood gas
l l l l l l l l l
, determinationsdrawn. Theimmediate priority, however,is theadministrationofoxyg l l l l l l l l l l
en.
Test-
Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply th
l l l l l l l l l l l l l l
e ABCs (airway, breathing, and circulation)to find the correctoption. Review the nursing
l l l l l l l l l l l l l
actions to be taken immediately in the event of pulmonary embolism if you had difficult
l l l l l l l l l l l l l l l
y with this question.
l l l
Level of Cognitive Ability: Applying Clie
l l l l l
ntNeeds: Physiological Integrity
l l l
Integrated Process:Nursing Process/ImplementationC l l l l
ontent Area: Delegating/Prioritizing
l l
Reference: Ignatavicius, D., & Workman, M. (2010). Medical- l l l l l l l
surgical nursing:Patient- l l
centered collaborative care (6th ed., p. 680). St. Louis:Saunders.
l l l l l l l l l
• A nurse is assessing a client who has a closed chest tube drainage system. Thenurs
l l l l l l l l l l l l l l l
e notes constant bubbling in the water seal chamber. What actions should the nurse
l l l l l l l l l l l l l
take? (Select all that apply).
l l l l l
Clamping the chest tube Chang l l l l
ingthe drainage system
l l l
cP S D| 287692 25
• A client who just returned from the recovery room after a tonsillectomy and aden
l l l l l l l l l l l l l
oidectomy is restless and her pulse rate is increased. As the nurse continues the asse
l l l l l l l l l l l l l l
ssment, the client begins to vomit a copious amount of bright-
l l l l l l l l l l
red blood. The immediate nursing action is to:
l l l l l l l l
Notify the surgeon Contin l l l
ue 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 and adenoide
l l l l l l l l l
ctomy. If the client vomits a large amount of bright-
l l l l l l l l l
red blood or the pulse rate increases and the patient is restless, the nurse must notify t
l l l l l l l l l l l l l l l l
he surgeonimmediately. The nurse shouldobtaina light, mirror, gauze, curved hemost
l l l l l l l l l l l l
at, andwaste basin to facilitate examination of the surgical site. The nurse should also
l l l l l l l l l l l l l l l
gather additional assessment data, but the surgeon must be contacted immediately.
l l l l l l l l l l
Test-TakingStrategy:Focus onthe data in the question. Noting thewords“bright-
l l l l l l l l l l l l
red blood” will assist in directing you to the correct option. Remember that the
l l l l l l l l l l l l l l
,presence of bright- l l
red blood indicates active bleeding. Review the nursing actionsto be taken immediate
l l l l l l l l l l l l
ly when bleeding occurs after a tonsillectomy and adenoidectomy if you had difficulty
l l l l l l l l l l l l l
with this question. l l
Level of Cognitive Ability: Applying Clie
l l l l l
ntNeeds: Physiological Integrity
l l l
Integrated Process:Nursing Process/ImplementationC l l l l
ontent Area: Delegating/Prioritizing l l
Reference: Ignatavicius, D., & Workman, M. (2010). Medical- l l l l l l l
surgical nursing:Patient- l l
centered collaborative care (6th ed., p. 657). St. Louis:Saunders.
l l l l l l l l l
• A client who has just undergone surgery suddenly experiences chest pain,dys
l l l l l l l l l l l
pnea, and tachypnea. The nurse suspects that the client has a pulmonary embo
l l l l l l l l l l l l
lism and immediately sets about:
l l l l
Preparing the client for a perfusion scan Attaching t l l l l l l l l
he client to a cardiac monitor Administering oxyge
l l l l l l l
n by way of nasal cannula Ensuring that the intrave
l l l l l l l l l
nous (IV) line is patent l l l l
Rationale:Pulmonaryembolism is a life-threatening emergency. Oxygen is l l l l l l l l
immediately administered nasally to relieve hypoxemia, respiratory distress, and cent l l l l l l l l l
ral cyanosis, and the physician is notified. IV infusion lines are needed to administer me
l l l l l l l l l l l l l l
dications or fluids. A perfusion scan, among other tests, may be performed. The electro
l l l l l l l l l l l l l
cardiogram is monitored for the presence of dysrhythmias.Additionally, a urinary cathe
l l l l l l l l l l l
,ter may be inserted and blood for arterial blood gas
l l l l l l l l l
, determinationsdrawn. Theimmediate priority, however,is theadministrationofoxyg l l l l l l l l l l
en.
Test-
Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply th
l l l l l l l l l l l l l l
e ABCs (airway, breathing, and circulation)to find the correctoption. Review the nursing
l l l l l l l l l l l l l
actions to be taken immediately in the event of pulmonary embolism if you had difficult
l l l l l l l l l l l l l l l
y with this question.
l l l
Level of Cognitive Ability: Applying Clie
l l l l l
ntNeeds: Physiological Integrity
l l l
Integrated Process:Nursing Process/ImplementationC l l l l
ontent Area: Delegating/Prioritizing
l l
Reference: Ignatavicius, D., & Workman, M. (2010). Medical- l l l l l l l
surgical nursing:Patient- l l
centered collaborative care (6th ed., p. 680). St. Louis:Saunders.
l l l l l l l l l
• A nurse is assessing a client who has a closed chest tube drainage system. Thenurs
l l l l l l l l l l l l l l l
e notes constant bubbling in the water seal chamber. What actions should the nurse
l l l l l l l l l l l l l
take? (Select all that apply).
l l l l l
Clamping the chest tube Chang l l l l
ingthe drainage system
l l l
