A male client who had abdominal surgery 5 days ago and was hospitalized because of a 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.
Notify the healthcare provider.
Obtain sterile towels soaked in saline.
Assure the client that such feelings occur with wound infections.
The Correct Answer is A
Choice A reason:
The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.
Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.
Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.
Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because increasing the intake of insoluble fiber can help prevent constipation and reduce the risk of diverticulitis by promoting regular bowel movements.
Choice B reason: Augmenting intake of dairy products is not specific to managing diverticulosis.
Choice C reason: Eliminating caffeine and chocolate is not necessary unless these foods cause symptoms.
Choice D reason: While reducing high-fat foods is good dietary advice, it is not specific to diverticulosis management.
An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and reports a dry mouth. Which intervention should the nurse implement?
a) Encourage the client to drink water.
b) Administer a prescribed sedative.
c) Apply a high-flow Venturi mask.
d) Assist the client to an upright position.
The correct answer is: d) Assist the client to an upright position.
Choice A reason: Encouraging the client to drink water is beneficial but does not address the immediate need to ease breathing.
Choice B reason: Administering a sedative may help with anxiety but does not directly address the respiratory issue.
Choice C reason: Applying a high-flow Venturi mask may be necessary if oxygen saturation is low, but the first step should be to position the client for optimal breathing.
Choice D reason:
The correct answer is d) because assisting the client to an upright position can help ease breathing by allowing for better lung expansion.
Correct Answer is A
Explanation
Choice A reason:
The correct answer is a) because a bounding pulse, hypertension, and distended neck veins are signs of fluid overload, which can occur during blood transfusions, especially in older adults.
Choice B reason: A thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload.
Choice C reason: Urticaria, itching, and wheezing suggest an allergic reaction, not fluid overload.
Choice D reason: Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload.
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