A nurse in an urgent care center is collecting data from a client who reports taking an excessive amount of aspirin. Which of the following findings should the nurse identify as an indication of salicylism?

Joint pain

Diuresis

Tinnitus

Respiratory depression

Answer and Explanation

The Correct Answer is C

A. Joint pain is not typically associated with salicylism; it is more likely related to underlying conditions such as arthritis.

B. Diuresis, or increased urination, is not a common sign of salicylism.

C. Tinnitus, or ringing in the ears, is a classic symptom of salicylism and is often one of the first signs of aspirin toxicity.

D. Respiratory depression is more associated with opioid overdose, whereas salicylism can cause respiratory alkalosis initially.

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Correct Answer is A

Explanation

A. Paralytic ileus is a common postoperative complication characterized by the absence of bowel sounds, abdominal distention, and failure to pass flatus due to a lack of intestinal peristalsis.

B. Incisional infection would typically present with localized symptoms such as redness, warmth, and purulent drainage at the surgical site, not generalized abdominal distention and lack of bowel sounds.

C. Health care-associated Clostridium difficile infection usually presents with diarrhea, not an absence of bowel sounds or abdominal distention.

D. Fecal impaction is more likely to cause localized pain and possible leakage of liquid stool, rather than complete absence of bowel sounds and severe distention.

A. Use sterile gloves to place gentle pressure on the exposed organs. B. Have the client lie supine with legs straight. C. Cover the area with saline-soaked sterile dressings. D. Gently suction secretions from the wound bed using a 12 gauge sterile catheter.

Correct Answer is C

Explanation

A. Placing pressure on exposed organs is not appropriate and could cause further damage.

B. Having the client lie supine with legs straight could increase tension on the abdominal wound and exacerbate the evisceration.

C. Covering the eviscerated organs with saline-soaked sterile dressings is the correct intervention to protect the organs from infection and prevent them from drying out while waiting for emergency surgical intervention.

D. Suctioning secretions from the wound bed is not appropriate and could cause additional trauma to the exposed organs.

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A nurse in an urgent care center is collecting data from a client who reports taking an excessive amount of aspirin. Which of the following findings should the nurse identify as an indication of salicylism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Correct Answer is A

Explanation

A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Correct Answer is C

Explanation

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Signs of Salicylate toxicity include all of the following except:

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