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. While postmenopausal use of herbal estrogen may be a risk factor for breast cancer, it is not as significant as having a family history of the disease.
B. A history of fibrocystic changes and a painful lump are not as strong a risk factor for breast cancer as a family history of the disease.
C. Being of normal weight, height, and having children at a younger age are generally considered protective factors rather than risk factors for breast cancer.
D. A non-tender lump combined with a family history of breast cancer (mother with breast cancer) is the most significant risk factor for developing breast cancer.

A. Apply an ice pack for 20 minutes to the episiotomy. B. Observe suture line for separation and hematoma formation. C. Initiate daily warm sitz baths during onset of pain. D. Check medication administration record for last PRN analgesic.

Correct Answer is B

Explanation

A. Applying an ice pack can help manage pain and reduce swelling, but it is not the immediate priority. It is essential first to assess for complications that may require different interventions.
B. Observing the suture line for separation and hematoma formation is the first step in managing pain. Identifying possible complications like suture line issues or hematomas will guide the appropriate treatment.
C. Initiating warm sitz baths is beneficial for pain management and healing, but it should be done after assessing the episiotomy for potential complications. It is a supportive measure rather than an immediate assessment action.
D. Checking the medication administration record is relevant for managing pain but is secondary to assessing the condition of the episiotomy site. The first priority is to evaluate the site for any physical complications.

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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

A 56-year-old female client has discovered a new breast lump. The practical nurse (PN) recognizes that this client's greatest risk for a diagnosis of breast cancer is related to which factor?

Correct Answer is D

Explanation

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

Correct Answer is B

Explanation

Exhibits Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an older adult client has a radial pulse of 55 beats/minute. Which intervention should the PN implement first?

In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN, "Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

A 2-month-old client is brought to the well-baby clinic. The parent is completing the consent forms for routine infant immunizations. Which immunization should the practical nurse (PN) prepare to administer?