MED SURG REAL EXAM WITH QUESTIONS AND ANSWERS WITH RATIONALES TEST TAKING STRATEGIES AND REFERENCES

MED SURG REAL EXAM WITH
QUESTIONS AND ANSWERS
WITH RATIONALES TEST
TAKING STRATEGIES AND
REFERENCES
• 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 surgeon
immediately. The nurse should obtain a light, mirror, gauze, curved hemostat, and
waste 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 “brightred blood” will assist in directing you to the correct option. Remember that the
presence of bright-red blood indicates active bleeding. Review the nursing actions
to 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/Implementation
Content 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, and
central cyanosis, and the physician is notified. IV infusion lines are needed to
administer medications or fluids. A perfusion scan, among other tests, may be
performed. The electrocardiogram is monitored for the presence of dysrhythmias.
Additionally, a urinary catheter may be inserted and blood for arterial blood gas
determinations drawn. The immediate priority, however, is the administration of
oxygen.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of
prioritizing. Apply the ABCs (airway, breathing, and circulation) to find the correct
option. Review the nursing actions to be taken immediately in the event of
pulmonary embolism if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 680). St. Louis:
Saunders.