NURS 371 MED SURG REAL EXAM QUESTIONS AND ANSWERS
LATEST SOLUTIONS GRADED A
• 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 sterilesaline 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 whenwound
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/ImplementationContent
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.
• 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 surgeonimmediately. The nurse should obtain a light,
mirror, gauze, curved hemostat, andwaste 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 actionsto 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/ImplementationContent
Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-
centered collaborative care (6th ed., p. 657). St. Louis:Saunders.
• 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 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, andcentral cyanosis,
and the physician is notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be
LATEST SOLUTIONS GRADED A
• 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 sterilesaline 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 whenwound
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/ImplementationContent
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.
• 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 surgeonimmediately. The nurse should obtain a light,
mirror, gauze, curved hemostat, andwaste 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 actionsto 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/ImplementationContent
Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-
centered collaborative care (6th ed., p. 657). St. Louis:Saunders.
• 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 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, andcentral cyanosis,
and the physician is notified. IV infusion lines are needed to administer medications or fluids. A
perfusion scan, among other tests, may be
