An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?

Monitor skin for breakdown.

Strict intravenous (IV) fluid replacement.

Encourage regular turning.

Assess wound drainage daily.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice B rationale
An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous
(IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure.
Choice C rationale
Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice D rationale
Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.

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Correct Answer is B

Explanation

Gouty arthritis is a form of inflammatory arthritis that occurs when uric acid crystals accumulate in the joints, causing severe pain and inflammation. Drinking plenty of water can help to flush the uric acid out of the body, reducing the risk of crystal formation and subsequent inflammation.

A. Superficial partial-thickness. B. Full-thickness. C. Deep partial-thickness. D. Deep full-thickness.

Correct Answer is B

Explanation

Choice A rationale
A superficial partial-thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. The description provided does not match this type of burn.
Choice B rationale
A full-thickness burn involves total destruction of the epidermis and dermis, and in some cases, the underlying tissue, muscle, and bone. The description of the burn as severely swollen, with a wound bed that appears brown and yellow, and the patient reporting no pain, is consistent with a full-thickness burn.
Choice C rationale
A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. The description provided does not match this type of burn.
Choice D rationale
Deep full-thickness burns are a more severe form of full-thickness burns that extend beyond the dermis into deeper tissues. The description provided does not match this type of burn.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?

Correct Answer is B

Explanation

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

Correct Answer is B

Explanation

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan? (Select all that apply.)

A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?

The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?