HESI Medical Surgical Review Questions With Answers (244 Solved Questions)

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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 thepresence of wound dehiscence. The nurse immediately:Contacts the physicianDocuments the findingsPlaces the client in a supine position with the legs flatCovers the abdominal wound with a sterile dressing moistened with sterile saline solutionRationale: Wound dehiscence is the disruption of a surgical incision or wound. Whendehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supinewith the knees bent and instructs the client to lie quietly. These actions will minimize protrusionof the underlying tissues. The nurse then covers the wound with a sterile dressing moistenedwith sterile saline. The physician is notified, and the nurse documents the occurrence and thenursing 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 when wound dehiscence occurs isthe protrusion of underlying tissues. This will direct you to the correct option. Review the nursingactions to be taken immediately in the event of wound dehiscence if you had difficulty with thisquestion.A client who just returned from the recovery room after a tonsillectomy and adenoidectomy isrestless and her pulse rate is increased. As the nurse continues the assessment, the clientbegins to vomit a copious amount of bright-red blood. The immediate nursing action is to:Notify the surgeonContinue the assessmentCheck the client’s blood pressureObtain a flashlight, gauze, and a curved hemostatRationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If theclient vomits a large amount of bright-red blood or the pulse rate increases and the patient isrestless, 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. Thenurse should also gather additional assessment data, but the surgeon must be contactedimmediately.Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” willassist in directing you to the correct option. Remember that the presence of bright-red bloodindicates active bleeding. Review the nursing actions to be taken immediately when bleedingoccurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.

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