HESI MED SURG EXAM QUESTIONS AND ANSWERS with RATIONALES TEST TAKING STRATEGIES AND REFERENCE 2024

HESI MED SURG EXAM QUESTIONS AND ANSWERS with RATIONALES TEST TAKING STRATEGIES AND REFERENCE 2024

HESI MED SURG EXAM QUESTIONS AND ANSWERS,
RATIONALES, TEST TAKING STRATEGIES AND
REFERENCE.
. 1.ID: 9477047208
. 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 should
take which immediate action?
A. Document the findings
B. Contact the health care provider
C. Place the client in a supine position with the legs flat
D. Cover the abdominal wound with a sterile dressing moistened with
sterile saline 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 health care provider is notified, and the nurse documents the
occurrence and the nursing actions that were implemented in response.
. Test-Taking Strategy: Note the strategic word “immediate.” Visualize this
occurrence and recall that the primary concern when wound 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
. Level of Cognitive Ability: Applying
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Implementation
. Content Area: Perioperative Care
. Giddens Concepts: Caregiving, Tissue Integrity
. HESI Concepts: Caregiving, Tissue Integrity
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., p. 180). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
. 2.ID: 9477054249
. A client who just returned from the recovery room after a tonsillectomy and
adenoidectomy is restless and the pulse rate is increased. As the nurse
continues the assessment, the client begins to vomit a copious amount of
bright-red blood. The nurse should take which immediate action?
A. Notify the surgeon Correct
B. Continue the assessment
C. Check the client’s blood pressure
D. 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, t