Exhibits

The client has recovered from surgery and is ready to be discharged.

Highlight findings that indicate the client is stable and ready to be discharged.

The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.

The incision dressing is dry and intact, and no bleeding is noted

The client tolerated clear liquids post recovery and has advanced to a soft diet

The client ambulated around the unit this morning and tolerated activity well

Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus

Pain is tolerated with analgesia PO

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.

Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.

Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.

Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.

Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.

Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Watery diarrhea is a potential sign of Clostridium difficile (C. diff) infection, a serious and common complication associated with antibiotics like linezolid.

B. Nausea and headache are side effects but are less urgent than symptoms suggesting C. diff.

C. Increased fatigue is non-specific and may be related to the infection or the medication, but it is not as immediately concerning as diarrhea.

D. Yellow-tinged sputum is typical of pneumonia and does not indicate an urgent issue related to linezolid therapy.

A. Advance from clear liquids as tolerated. B. Straight catheterization if unable to void. C. Cefazolin 1 gram IV every 6 hours. D. Complete blood cell count (CBC) in AM.

Correct Answer is C

Explanation

A. Advancing to clear liquids is important for nutritional support but is secondary to ensuring urinary function is restored.

B. Urinary retention is a concern after anesthesia, but it is not an immediate threat. This intervention is conditional (“if unable to void”), meaning it is implemented only if needed.

C. Postoperative clients are at high risk for infection. Cefazolin (a broad-spectrum antibiotic) is a prophylactic measure to reduce the risk of surgical site infection, which is a priority intervention immediately after surgery. This should be implemented first, since infection prevention begins as soon as the client arrives from PACU.

D. A CBC is important for monitoring but is not urgent in comparison to immediate care needs like urinary output.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is C

Explanation

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Exhibits The nurse is caring for the client the morning after her surgery. Click to select the 5 most important nursing interventions for postoperative client care.

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