MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
MEDSURG l
Alclientlwholhaslundergonelabdominallsurgerylcallslthelnurselandlreportslthatlsheljustlfeltl“somethinglgivel
way”linlthelabdominallincision.lThelnurselcheckslthelincisionlandlnoteslthelpresenceloflwoundldehiscence.l
Thelnurselimmediately:
ContactslthelphysicianlIncorrect
Documentslthelfindings
Placeslthelclientlinlalsupinelpositionlwithlthellegslflat
CoverslthelabdominallwoundlwithlalsterileldressinglmoistenedlwithlsterilelsalinelsolutionlCorrect
Rationale:lWoundldehiscencelisltheldisruptionloflalsurgicallincisionlorlwound.lWhenldehiscenceloccurs,lthel
nurselimmediatelylplaceslthelclientlinlallowlFowler’slpositionlorlsupinelwithlthelkneeslbentlandlinstructslthel
clientltollielquietly.lTheselactionslwilllminimizelprotrusionloflthelunderlyingltissues.lThelnurselthenlcoverslth
elwoundlwithlalsterileldressinglmoistenedlwithlsterilelsaline.lThelphysicianlislnotified,landlthelnurseldocum
entsltheloccurrencelandlthelnursinglactionslthatlwerelimplementedlinlresponse.
Test-
TakinglStrategy:lUselthelprocesslofleliminationlandlnotelthelstrategiclwordl“immediately.”lVisualizelthisloc
currencelandlrecalllthatlthelprimarylconcernlwhenlwoundldehiscenceloccurslislthelprotrusionloflunderlyingl
tissues.lThislwillldirectlyoultolthelcorrectloption.lReviewlthelnursinglactionsltolbeltakenlimmediatelylinlthele
ventloflwoundldehiscenceliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lPerioperativelCare
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lpp.l291,l292,l296).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l2.
ID:l383740621
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
Alclientlwholjustlreturnedlfromlthelrecoverylroomlafterlaltonsillectomylandladenoidectomylislrestlesslandl
herlpulselratelislincreased.lAslthelnurselcontinueslthelassessment,lthelclientlbeginsltolvomitlalcopiouslamo
untloflbright-redlblood.lThelimmediatelnursinglactionlislto:
NotifylthelsurgeonlCorrectl
Continuelthelassessment
Checklthelclient’slbloodlpressure
Obtainlalflashlight,lgauze,landlalcurvedlhemostat
Rationale:lHemorrhagelislalpotentiallcomplicationlafterltonsillectomylandladenoidectomy.lIflthelclientlvo
mitslallargelamountloflbright-
redlbloodlorlthelpulselratelincreaseslandlthelpatientlislrestless,lthelnurselmustlnotifylthelsurgeonlimmediat
ely.lThelnurselshouldlobtainlallight,lmirror,lgauze,lcurvedlhemostat,landlwastelbasinltolfacilitatelexaminati
onloflthelsurgicallsite.lThelnurselshouldlalsolgatherladditionallassessmentldata,lbutlthelsurgeonlmustlbelco
ntactedlimmediately.
Test-TakinglStrategy:lFocuslonltheldatalinlthelquestion.lNotinglthelwordsl“bright-
redlblood”lwilllassistlinldirectinglyoultolthelcorrectloption.lRememberlthatlthelpresenceloflbright-
redlbloodlindicateslactivelbleeding.lReviewlthelnursinglactionsltolbeltakenlimmediatelylwhenlbleedinglocc
urslafterlaltonsillectomylandladenoidectomyliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lDelegating/Prioritizing
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lp.l657).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l3.
ID:l383739348
Alclientlwholhasljustlundergonelsurgerylsuddenlylexperienceslchestlpain,ldyspnea,landltachypnea.lThelnurs
elsuspectslthatlthelclientlhaslalpulmonarylembolismlandlimmediatelylsetslabout:
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
PreparinglthelclientlforlalperfusionlscanlAt
tachinglthelclientltolalcardiaclmonitor
AdministeringloxygenlbylwayloflnasallcannulalCorrect
Ensuringlthatlthelintravenousl(IV)llinelislpatent
Rationale:lPulmonarylembolismlislallife-
threateninglemergency.lOxygenlislimmediatelyladministeredlnasallyltolrelievelhypoxemia,lrespiratoryldistr
ess,landlcentrallcyanosis,landlthelphysicianlislnotified.lIVlinfusionllineslarelneededltoladministerlmedication
slorlfluids.lAlperfusionlscan,lamonglotherltests,lmaylbelperformed.lThelelectrocardiogramlislmonitoredlforlt
helpresencelofldysrhythmias.lAdditionally,lalurinarylcatheterlmaylbelinsertedlandlbloodlforlarteriallbloodlga
sldeterminationsldrawn.lThelimmediatelpriority,lhowever,lisltheladministrationlofloxygen.
Test-
TakinglStrategy:lFocuslonlthelclient’sldiagnosislandluselthelskillsloflprioritizing.lApplylthelABCsl(airway,lbr
eathing,landlcirculation)ltolfindlthelcorrectloption.lReviewlthelnursinglactionsltolbeltakenlimmediatelylinl
theleventloflpulmonarylembolismliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lDelegating/Prioritizing
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lp.l680).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l4.
ID:l383738703
Alnurselislassessinglalclientlwholhaslalclosedlchestltubeldrainagelsystem.lThelnurselnoteslconstantlbubb
linglinlthelwaterlseallchamber.lWhatlactionslshouldlthelnurseltake?l(Selectlalllthatlapply).
ClampinglthelchestltubelChang
ingltheldrainagelsystem
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
AssessinglthelsystemlforlanlexternallairlleaklCorrectlRe
ducingltheldegreeloflsuctionlbeinglapplied
Documentinglassessmentlfindings,lactionsltaken,landlclientlresponselCorrect
Rationale:lConstantlbubblinglinlthelwaterlseallchamberloflalclosedlchestltubeldrainagelsystemlmaylindicatel
thelpresenceloflanlairlleak.lThelnurselwouldlassesslthelchestltubelsystemlforlthelpresenceloflanlexternallairll
eakliflconstantlbubblinglwerelnotedlinlthislchamber.lIflanlexternallairlleaklislnotlpresentlandlthelairlleaklislalne
wloccurrence,lthelphysicianlislnotifiedlimmediately,lbecauselanlairlleaklmaylbelpresentlinlthelpleurallspace.l
Leakagelandltrappingloflairlinlthelpleurallspacelcanlresultlinlaltensionlpneumothorax.lClampinglthelchestltub
elislincorrect.lAdditionally,lalchestltubelislnotlclampedlunless
thislhaslbeenlspecificallylprescribedlinlthelagency’slpolicieslandlprocedures.lChangingltheldrainagelsyste
mlwilllnotlalleviatelthelproblem.lReducingltheldegreeloflsuctionlbeinglappliedlwilllnotlaffectlthelbubblingli
nlthelwaterlseallchamberlandlcouldlbelharmful.lThelnurselwouldldocumentlthelassessmentlfindingslandlin
terventionsltakenlinlthelclient’slmedicallrecord.
Test-
TakinglStrategy:lUselthelprocesslofleliminationlandlyourlknowledgelregardinglthelprioritylactionslinlthelcarel
oflalclosedlchestltubeldrainagelsystem.lFocuslonltheldatalinlthelquestion,lnotinglthatltherelislbubblinglinlthel
waterlseallchamber.lRecallinglthatlthislmaylindicatelanlairlleaklwillldirectlyoultolthelcorrectloptions.lReviewlt
helnursinglactionsltolbeltakenlimmediatelylinltheleventlthatlcomplicationsloflalclosedlchestltubeldrainagelsy
stemloccurliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lAdultlHealth/Respiratory
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lpp.l648,l649).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l5.
ID:l383739392
Alnurselislhelpinglalclientlwithlalclosedlchestltubeldrainagelsystemlgetloutloflbedlandlintolalchair.lDuringl
theltransfer,lthelchestltubelislcaughtlonlthellegloflthelchairlandldislodgedlfromlthelinsertionlsite.lThelim
mediatelprioritylonlthelpartloflthelnurselis:
l l l l l l l
MEDSURG l
Alclientlwholhaslundergonelabdominallsurgerylcallslthelnurselandlreportslthatlsheljustlfeltl“somethinglgivel
way”linlthelabdominallincision.lThelnurselcheckslthelincisionlandlnoteslthelpresenceloflwoundldehiscence.l
Thelnurselimmediately:
ContactslthelphysicianlIncorrect
Documentslthelfindings
Placeslthelclientlinlalsupinelpositionlwithlthellegslflat
CoverslthelabdominallwoundlwithlalsterileldressinglmoistenedlwithlsterilelsalinelsolutionlCorrect
Rationale:lWoundldehiscencelisltheldisruptionloflalsurgicallincisionlorlwound.lWhenldehiscenceloccurs,lthel
nurselimmediatelylplaceslthelclientlinlallowlFowler’slpositionlorlsupinelwithlthelkneeslbentlandlinstructslthel
clientltollielquietly.lTheselactionslwilllminimizelprotrusionloflthelunderlyingltissues.lThelnurselthenlcoverslth
elwoundlwithlalsterileldressinglmoistenedlwithlsterilelsaline.lThelphysicianlislnotified,landlthelnurseldocum
entsltheloccurrencelandlthelnursinglactionslthatlwerelimplementedlinlresponse.
Test-
TakinglStrategy:lUselthelprocesslofleliminationlandlnotelthelstrategiclwordl“immediately.”lVisualizelthisloc
currencelandlrecalllthatlthelprimarylconcernlwhenlwoundldehiscenceloccurslislthelprotrusionloflunderlyingl
tissues.lThislwillldirectlyoultolthelcorrectloption.lReviewlthelnursinglactionsltolbeltakenlimmediatelylinlthele
ventloflwoundldehiscenceliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lPerioperativelCare
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lpp.l291,l292,l296).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l2.
ID:l383740621
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
Alclientlwholjustlreturnedlfromlthelrecoverylroomlafterlaltonsillectomylandladenoidectomylislrestlesslandl
herlpulselratelislincreased.lAslthelnurselcontinueslthelassessment,lthelclientlbeginsltolvomitlalcopiouslamo
untloflbright-redlblood.lThelimmediatelnursinglactionlislto:
NotifylthelsurgeonlCorrectl
Continuelthelassessment
Checklthelclient’slbloodlpressure
Obtainlalflashlight,lgauze,landlalcurvedlhemostat
Rationale:lHemorrhagelislalpotentiallcomplicationlafterltonsillectomylandladenoidectomy.lIflthelclientlvo
mitslallargelamountloflbright-
redlbloodlorlthelpulselratelincreaseslandlthelpatientlislrestless,lthelnurselmustlnotifylthelsurgeonlimmediat
ely.lThelnurselshouldlobtainlallight,lmirror,lgauze,lcurvedlhemostat,landlwastelbasinltolfacilitatelexaminati
onloflthelsurgicallsite.lThelnurselshouldlalsolgatherladditionallassessmentldata,lbutlthelsurgeonlmustlbelco
ntactedlimmediately.
Test-TakinglStrategy:lFocuslonltheldatalinlthelquestion.lNotinglthelwordsl“bright-
redlblood”lwilllassistlinldirectinglyoultolthelcorrectloption.lRememberlthatlthelpresenceloflbright-
redlbloodlindicateslactivelbleeding.lReviewlthelnursinglactionsltolbeltakenlimmediatelylwhenlbleedinglocc
urslafterlaltonsillectomylandladenoidectomyliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lDelegating/Prioritizing
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lp.l657).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l3.
ID:l383739348
Alclientlwholhasljustlundergonelsurgerylsuddenlylexperienceslchestlpain,ldyspnea,landltachypnea.lThelnurs
elsuspectslthatlthelclientlhaslalpulmonarylembolismlandlimmediatelylsetslabout:
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
PreparinglthelclientlforlalperfusionlscanlAt
tachinglthelclientltolalcardiaclmonitor
AdministeringloxygenlbylwayloflnasallcannulalCorrect
Ensuringlthatlthelintravenousl(IV)llinelislpatent
Rationale:lPulmonarylembolismlislallife-
threateninglemergency.lOxygenlislimmediatelyladministeredlnasallyltolrelievelhypoxemia,lrespiratoryldistr
ess,landlcentrallcyanosis,landlthelphysicianlislnotified.lIVlinfusionllineslarelneededltoladministerlmedication
slorlfluids.lAlperfusionlscan,lamonglotherltests,lmaylbelperformed.lThelelectrocardiogramlislmonitoredlforlt
helpresencelofldysrhythmias.lAdditionally,lalurinarylcatheterlmaylbelinsertedlandlbloodlforlarteriallbloodlga
sldeterminationsldrawn.lThelimmediatelpriority,lhowever,lisltheladministrationlofloxygen.
Test-
TakinglStrategy:lFocuslonlthelclient’sldiagnosislandluselthelskillsloflprioritizing.lApplylthelABCsl(airway,lbr
eathing,landlcirculation)ltolfindlthelcorrectloption.lReviewlthelnursinglactionsltolbeltakenlimmediatelylinl
theleventloflpulmonarylembolismliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lDelegating/Prioritizing
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lp.l680).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l4.
ID:l383738703
Alnurselislassessinglalclientlwholhaslalclosedlchestltubeldrainagelsystem.lThelnurselnoteslconstantlbubb
linglinlthelwaterlseallchamber.lWhatlactionslshouldlthelnurseltake?l(Selectlalllthatlapply).
ClampinglthelchestltubelChang
ingltheldrainagelsystem
, MED SURG FORTIS COLLEGE Graded A+ , 2023
l l l l l l l
AssessinglthelsystemlforlanlexternallairlleaklCorrectlRe
ducingltheldegreeloflsuctionlbeinglapplied
Documentinglassessmentlfindings,lactionsltaken,landlclientlresponselCorrect
Rationale:lConstantlbubblinglinlthelwaterlseallchamberloflalclosedlchestltubeldrainagelsystemlmaylindicatel
thelpresenceloflanlairlleak.lThelnurselwouldlassesslthelchestltubelsystemlforlthelpresenceloflanlexternallairll
eakliflconstantlbubblinglwerelnotedlinlthislchamber.lIflanlexternallairlleaklislnotlpresentlandlthelairlleaklislalne
wloccurrence,lthelphysicianlislnotifiedlimmediately,lbecauselanlairlleaklmaylbelpresentlinlthelpleurallspace.l
Leakagelandltrappingloflairlinlthelpleurallspacelcanlresultlinlaltensionlpneumothorax.lClampinglthelchestltub
elislincorrect.lAdditionally,lalchestltubelislnotlclampedlunless
thislhaslbeenlspecificallylprescribedlinlthelagency’slpolicieslandlprocedures.lChangingltheldrainagelsyste
mlwilllnotlalleviatelthelproblem.lReducingltheldegreeloflsuctionlbeinglappliedlwilllnotlaffectlthelbubblingli
nlthelwaterlseallchamberlandlcouldlbelharmful.lThelnurselwouldldocumentlthelassessmentlfindingslandlin
terventionsltakenlinlthelclient’slmedicallrecord.
Test-
TakinglStrategy:lUselthelprocesslofleliminationlandlyourlknowledgelregardinglthelprioritylactionslinlthelcarel
oflalclosedlchestltubeldrainagelsystem.lFocuslonltheldatalinlthelquestion,lnotinglthatltherelislbubblinglinlthel
waterlseallchamber.lRecallinglthatlthislmaylindicatelanlairlleaklwillldirectlyoultolthelcorrectloptions.lReviewlt
helnursinglactionsltolbeltakenlimmediatelylinltheleventlthatlcomplicationsloflalclosedlchestltubeldrainagelsy
stemloccurliflyoulhadldifficultylwithlthislquestion.
LevelloflCognitivelAbility:lApplyinglCl
ientlNeeds:lPhysiologicallIntegrity
IntegratedlProcess:lNursinglProcess/Implementationl
ContentlArea:lAdultlHealth/Respiratory
Reference:lIgnatavicius,lD.,l&lWorkman,lM.l(2010).lMedical-surgicallnursing:lPatient-
centeredlcollaborativelcarel(6thled.,lpp.l648,l649).lSt.lLouis:lSaunders.
Awardedl0.0lpointsloutlofl1.0lpossiblelpoints.l5.
ID:l383739392
Alnurselislhelpinglalclientlwithlalclosedlchestltubeldrainagelsystemlgetloutloflbedlandlintolalchair.lDuringl
theltransfer,lthelchestltubelislcaughtlonlthellegloflthelchairlandldislodgedlfromlthelinsertionlsite.lThelim
mediatelprioritylonlthelpartloflthelnurselis:
