A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Visualize the abdominal incision.

Obtain sterile towels soaked in saline.

Assure the client that such feelings occur with wound infections.

Notify the healthcare provider

Answer and Explanation

The Correct Answer is A

A. Visualize the abdominal incision: The client’s description suggests a possible wound dehiscence or evisceration, which is a surgical emergency. The nurse’s immediate priority is to assess the site directly to confirm the condition before implementing further steps. Visual confirmation guides the urgency and next actions in management.

B. Obtain sterile towels soaked in saline: This is an essential intervention if evisceration is confirmed, as moist sterile dressings protect exposed abdominal organs from drying and infection. However, this should come only after the nurse visually inspects the wound to determine if evisceration has occurred.

C. Assure the client that such feelings occur with wound infections: This response dismisses the client's serious concern and does not address the potential for a severe surgical complication. While discomfort is expected with a wound infection, the feeling of "insides spilling out" is not a normal occurrence and requires immediate investigation.

D. Notify the healthcare provider: While the provider must be informed if evisceration or dehiscence is present, immediate nursing assessment comes first. The nurse must evaluate the situation and initiate necessary interventions like covering exposed organs before contacting the provider.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Signs of respiratory tract infection: While clients with diabetes may have a higher risk for infections due to immune compromise, respiratory infections are not typically considered long-term complications of diabetes. This assessment is more relevant for acute care rather than chronic complication monitoring.

B. Sensation in feet and legs: Peripheral neuropathy is a common long-term complication of diabetes due to prolonged hyperglycemia damaging peripheral nerves. Assessing sensation helps detect early nerve damage and prevent complications such as foot ulcers and injuries.

C. Skin condition of lower extremities: Poor circulation and neuropathy can lead to delayed wound healing, dry skin, and increased risk of infections or ulcers. Examining the skin condition of the lower extremities helps identify early signs of peripheral vascular disease and diabetic foot complications.

D. Visual acuity: Diabetic retinopathy is a major chronic complication of type 2 DM, potentially leading to vision loss. Regular assessment of visual acuity is essential to detect changes early and refer the patient for ophthalmologic evaluation if needed.

E. Serum creatinine and blood urea nitrogen (BUN): Diabetic nephropathy can lead to progressive kidney damage. Monitoring kidney function through serum creatinine and BUN helps assess renal involvement and guide interventions to slow disease progression.

A. Limit calories on days unable to exercise. B. Regular exercise with medical approval. C. Monitor blood glucose levels daily. D. Monthly appointments with the dietician.

Correct Answer is B

Explanation

A. Limit calories on days unable to exercise: While adjusting caloric intake is a useful strategy in managing blood glucose, inconsistent caloric restriction without a structured plan can lead to hypoglycemia or poor nutritional intake. This approach alone is insufficient for improving HDL levels, which are influenced more significantly by physical activity.

B. Regular exercise with medical approval: Engaging in consistent aerobic exercise enhances insulin sensitivity, helping to lower blood glucose levels. Physical activity also promotes cardiovascular health by raising HDL cholesterol, which offers protective benefits against atherosclerosis—an important concern in diabetic clients.

C. Monitor blood glucose levels daily: Daily glucose monitoring is essential for adjusting treatment and preventing complications, but it does not directly increase HDL levels. Monitoring provides data, but behavior changes like diet and exercise are what actively influence these health markers.

D. Monthly appointments with the dietician: Regular consultation with a dietitian supports nutritional management, but monthly visits may not have a timely or sufficient impact on HDL and glucose control. Lifestyle modifications, particularly regular exercise, offer more immediate and measurable effects in both areas.

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A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is B

Explanation

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