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 C

Explanation

Choice A reason: Bile-stained emesis indicates an obstruction, but it is not as immediately critical as a distended, hard, and rigid abdomen.

Choice B reason: Clay-colored stool is a sign of bile duct obstruction but is not as urgent as the abdomen findings.

Choice C reason:

The correct answer is c) because a distended, hard, and rigid abdomen suggests peritonitis or a perforated organ, which requires immediate medical intervention.

Choice D reason: Radiating, sharp pain in the right shoulder is common in gallbladder issues but is not as immediately life-threatening as a distended, hard, and rigid abdomen.

A. Warm, soft, moist, salmon-colored skin. B. Visible swelling of the neck, with no pain. C. Husky voice and troubled by hoarseness. D. Central-type obesity, with thin extremities.

Correct Answer is D

Explanation

Choice A reason: Warm, soft, moist, salmon-colored skin is not typical of Cushing's syndrome.

Choice B reason: Visible swelling of the neck, with no pain, is not specific to Cushing's syndrome.

Choice C reason: A husky voice and trouble with hoarseness are not typical of Cushing's syndrome.

Choice D reason:

The correct answer is d) because central-type obesity with thin extremities is a characteristic feature of Cushing's syndrome.

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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

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Correct Answer is C

Explanation

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

Correct Answer is D

Explanation

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