A post-surgical patient reports feeling a "pop" in their surgical wound to the nurse. The nurse noted pinkish drainage on the client's dressing. Upon assessment, the nurse noted a protruding bowel loop. What should be the nurse's immediate action?

Leave the room and notify the nursing supervisor

Treat the evisceration by covering area with sterile gauze pad soaked with sterile saline

Notify the patient's family

Instruct her to cough and deep breathe

Answer and Explanation

The Correct Answer is B

A. Leave the room and notify the nursing supervisor: Leaving the patient delays immediate wound protection and would abandon a patient with an acute surgical emergency; the priority is to protect exposed viscera and get help.

B. Treat the evisceration by covering area with sterile gauze pad soaked with sterile saline: Covering the exposed bowel with sterile, saline-moistened dressings reduces contamination, prevents tissue drying, and is the immediate priority while calling the surgeon/rapid response and keeping the patient NPO and supine.

C. Notify the patient's family: Informing family is important later, but it is not the immediate clinical action; stabilize and protect the patient first.

D. Instruct her to cough and deep breathe: Coughing increases intra-abdominal pressure and can worsen evisceration - this should be avoided.

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Correct Answer is B

Explanation

A. Protein is 1 gram: According to the nutrition label, there are 5 grams of protein per serving, not 1 gram. The client misunderstands how to read the protein content directly from the label.

B. Sodium content of the container is 940 mg: This statement is correct and demonstrates the client's understanding of the food label. The label shows the sodium content per serving, which is 470 mg. However, the container holds 2 servings. To find the total sodium for the entire container, the client correctly multiplies the sodium per serving by the number of servings: 470mg×2=940mg.

C. Sodium content of the container is 470 mg: The client correctly reads the sodium content per serving (470 mg) but fails to account for the 2 servings per container. This answer shows a misunderstanding of how to calculate the total nutritional content for the entire package.

D. No trans fat: The label clearly lists 3 grams of trans fat per serving. The client misunderstands the "0 g" listed under dietary fiber and applies it to trans fat, or simply misreads the label entirely.

A. 6 capsules B. 8 capsules C. 2 capsules D. 4 capsules

Correct Answer is A

Explanation

Each dose is 20 mg.

20 mg ÷ 10 mg per capsule = 2 capsules per dose.

TID = 3 doses/day → 2 × 3 = 6 capsules in 24 hours.

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A post-surgical patient reports feeling a "pop" in their surgical wound to the nurse. The nurse noted pinkish drainage on the client's dressing. Upon assessment, the nurse noted a protruding bowel loop. What should be the nurse's immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is prescribed Bentyl 20 mg PO TID. The drug is available in 10 mg capsules. How many capsules will he receive in 24 hours?

Correct Answer is A

Explanation

The physician prescribes Gabapentin 20 mg PO QID. The pharmacy has available Gabapentin syrup 10 mg/5 ml. The client should receive ml per day?

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A client reports to the nurse that they feel suddenly short of breath when in the supine position. The nurse should document this finding as which of the following?

A nurse explains the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?