Page 2613 - Saunders Comprehensive Review For NCLEX-RN

Rationale: In the first few hours after surgery, the drainage from the chest tube is
bloody. After several hours, it becomes serosanguineous. The client should not
experience frequent clotting. Proper chest tube function should allow for drainage of
blood before it has the chance to clot in the chest or the tubing.
Test-Taking Strategy: Focus on the subject, expected findings after thoracic
surgery. Recall that after thoracic surgery, there may be considerable capillary
oozing for hours in the postoperative period. This will lead you to choose the bloody
drainage option over the serous or serosanguineous drainage options. Knowing that
patent chest tubes do not allow blood to collect in the pleural space eliminates the
option of blood with clots.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Respiratory
Health Problem: N/A
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Lewis et al. (2017), pp. 524-525.

931. Answer: 1, 2, 3, 5

Rationale: If the client begins to hemorrhage from the surgical site after radical
neck dissection, the nurse elevates the head of the bed to maintain airway patency
and prevent aspiration. The nurse applies pressure over the bleeding site and calls
the surgeon immediately. The nurse also monitors the client’s airway and vital signs.
Test-Taking Strategy: Focus on the subject, nursing actions for hemorrhage, and
on the client situation. Use the ABCs—airway, breathing, and circulation—to assist
you in answering the question. Note that lowering the head of the bed to a flat
position increases the client’s risk for aspiration.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Cancer: Laryngeal and lung
Priority Concepts: Clinical Judgment; Gas Exchange
Reference: Lewis et al. (2017), pp. 494-495.

932. Answer: 2

Rationale: To prevent transmission of hepatitis, vaccination of the partner is
advised. In addition, a condom is advised during sexual intercourse. Alcohol should
be avoided because it is detoxified in the liver and may interfere with recovery. Rest
is especially important until laboratory studies show that liver function has returned
to normal. The client’s activity is increased gradually, and the client should not
return to work right away.
Test-Taking Strategy: Focus on the strategic words, need for further teaching. These
words indicate a negative event query and ask you to select an option that is
incorrect. Think about the pathophysiology associated with hepatitis to direct you to

2613