An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Evisceration.

Hemorrhage.

Infection.

Dehiscence.

Answer and Explanation

The Correct Answer is A

A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.

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Correct Answer is D

Explanation

A. Administering half of the missed dose is not generally recommended because it could lead to inconsistent drug levels and potential for breakthrough seizures. The standard practice is to follow the dosing schedule unless otherwise instructed by the healthcare provider.
B. Giving the missed dose with the next scheduled dose may lead to double dosing and could increase the risk of side effects or toxicity. The missed dose should be addressed as soon as possible but not in combination with the next dose.
C. Withholding the missed dose unless seizure activity occurs could put the client at risk for seizures. Anticonvulsants should be administered as per the prescribed schedule to maintain therapeutic drug levels and prevent seizures.
D. Administering the missed dose as soon as possible is the correct approach, following standard guidelines for missed medications. The missed dose should be given promptly unless it is close to the time of the next dose, in which case the next dose should be given as scheduled.

A. Have you changed any diapers? B. Have you unwrapped and looked at your baby? C. Have you noticed the baby sleeping? D. Has the family seen the baby yet?

Correct Answer is A

Explanation

A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.

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An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At 1200, the practical nurse (PN) learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

Correct Answer is D

Explanation

When the practical nurse (PN) prepares to transfer a 12-hour-old newborn from the birthing suite to the nursery, which question is most important for the PN to ask the mother?

Correct Answer is A

Explanation

Exhibits The practical nurse (PN) suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?

A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

What foods should the practical nurse (PN) recommend to a client as good sources of vitamin K? Select all that apply.

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action?