NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
,NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
,NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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.
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
, NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
,NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
,NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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.
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
, NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
.
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
NURSING 428 MED SURGE HESI REVIEW EXAM Q
& As ALL ANSWERS 100% COREECT ANSWERS
LATEST UPDATE 2022/2023 RATED A+ SCORE
