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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Sleeping flat in a supine position may increase intraocular pressure.

Choice B reason: Observing the pupil response of the right eye is not relevant to the left eye procedure.

Choice C reason: Turning, coughing, and deep breathing are important post-surgery but not specific to cataract extraction.

Choice D reason:

The correct answer is d) because administering a stool softener helps prevent straining during bowel movements, which can increase intraocular pressure.

A. Breathe deeply, followed by coughing up the sputum. B. Restrict fluids before expectorating the sputum specimen. C. Obtain the specimen before bedtime. D. Avoid mouth care prior to collecting the sputum.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because taking deep breaths followed by coughing helps produce a sputum sample from the lungs, which is necessary for accurate diagnostic testing.

Choice B reason: Restricting fluids before expectorating the sputum specimen is not necessary and may make it more difficult to produce a sample.

Choice C reason: Sputum specimens are best collected in the morning when secretions have accumulated overnight.

Choice D reason: Mouth care should be performed prior to sputum collection to reduce contamination from oral bacteria.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with lens implant?

Correct Answer is D

Explanation

The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum sample?

Correct Answer is A

Explanation

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