A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Encourage ambulation only after 48 hours post-surgery.

Instruct clients to avoid coughing to prevent wound dehiscence.

Monitor for signs of infection, such as fever or redness.

Remove surgical dressings within 12 hours post-surgery.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging ambulation only after 48 hours delays recovery, as early ambulation (within 12-24 hours) promotes circulation, prevents thromboembolism, and aids bowel function post-abdominal surgery. This instruction is incorrect, as it contradicts evidence-based protocols for early mobilization to enhance recovery.
Choice B reason: Instructing clients to avoid coughing is inappropriate, as coughing and deep breathing prevent pulmonary complications like atelectasis post-abdominal surgery. Splinting the incision during coughing reduces discomfort and dehiscence risk, making this instruction incorrect as it increases respiratory complications.
Choice C reason: Monitoring for signs of infection, such as fever or redness, is critical post-abdominal surgery to detect complications early. Infections can delay healing and lead to sepsis. Regular assessment ensures timely intervention, aligning with evidence-based postoperative care, making this the correct information to include.
Choice D reason: Removing surgical dressings within 12 hours is not standard, as dressings typically remain for 24-48 hours or per surgeon orders to protect the wound and reduce infection risk. Premature removal increases contamination risk, making this instruction incorrect for postoperative care.

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Correct Answer is C

Explanation

Choice A reason: Disulfiram is an oral medication, not injectable, used to deter alcohol consumption by causing adverse reactions. Monthly injections apply to drugs like naltrexone, not disulfiram, which requires daily oral dosing to maintain its deterrent effect in alcohol use disorder treatment.
Choice B reason: Taking disulfiram before quitting alcohol is incorrect, as it is started post-abstinence to prevent relapse. Disulfiram inhibits aldehyde dehydrogenase, causing acetaldehyde buildup if alcohol is consumed, making it effective only in alcohol-free clients to deter drinking.
Choice C reason: Avoiding over-the-counter medications with alcohol is correct, as disulfiram causes severe reactions (nausea, flushing) with alcohol ingestion, including from medications like cough syrups. This reflects understanding of disulfiram’s mechanism, ensuring safety by preventing unintended alcohol exposure.
Choice D reason: Continuing disulfiram for 5 years is not standard, as duration varies per treatment plan. Disulfiram supports early abstinence, not fixed long-term use. This statement misrepresents its role, as therapy length depends on individual recovery needs, not a predetermined timeframe.

A. Experiencing delusions B. A history of being in prison C. A history of violent behavior D. Substance use disorder

Correct Answer is C

Explanation

Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.

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A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

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