A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:

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ATI Detailed Answer Key Medical Surgical Questions

Question 1 of 5

A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:

Correct Answer: C

Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.

Question 2 of 5

A client is scheduled for a pneumonectomy in the morning. The client has had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:

Correct Answer: A

Rationale: Providing an opportunity for an open discussion will help to clarify any misunderstandings about the surgery and gives the client a chance to verbalize any concerns about the surgery. Distractions will not alleviate the client's preoperative anxiety; it denies the anxiety the client is experiencing. Giving false assurance is not appropriate and it denies that anxiety is a normal response to the threat of surgery. Psychological responses are not directly related to the severity of the surgery; they are influenced by the client's experience.

Question 3 of 5

Which of the following would be appropriate to delegate to the nursing assistant?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

What information should be immediately reported to the physician?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

What is the priority nursing action for this patient?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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