A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Trendelenburg with legs extended

Supine with knees flexed

Semi-Fowler's with legs extended

Left-lateral with knees flexed

Answer and Explanation

The Correct Answer is B

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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Correct Answer is D

Explanation

A. "Do you have any pain this morning?": This is a yes/no question that doesn't provide information about the pain's quality.
B. "Is your pain the same as it has been?": This assesses changes in pain, not its quality.
C. "Could you rate your pain on a scale from 0 to 10?": This measures the intensity of pain, not its quality.
D. "What does your pain feel like?": Asking about the quality of pain focuses on its nature (e.g., sharp, dull, throbbing, or burning). This helps determine the pain's characteristics.

A. "It is common for the skin on my breasts to dimple." B. "I will perform breast exams every other month." C. "It is common for one breast to be larger than the other." D. "I will perform breast exams the day my period begins."

Correct Answer is C

Explanation

A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

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A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client about her current pain status. Which of the following questions should the nurse ask to determine the quality of the client's pain?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

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