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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Obtaining a history of recent bleeding and anticoagulant use is essential but should not delay immediate stabilization.
B. Elevating the head of the bed to 30 degrees helps reduce intracranial pressure and promotes cerebral perfusion, which is a priority in stroke management.
C. Sequential compression devices (SCDs) are useful for preventing deep vein thrombosis (DVT) but are not an immediate intervention.
D. Elevating dependent joints on the affected side does not have immediate benefits for stroke management.

A. Establish a structured routine for the client to follow. B. Arrange a meeting with the family to discuss the client's situation. C. Assess the client's ability to communicate with the other staff members. D. Administer the client's antidepressant medication as prescribed.

Correct Answer is A

Explanation

A. Establish a structured routine for the client to follow. Establishing a consistent routine is essential to help clients with depression manage their symptoms and create a sense of structure and control. It can also help them feel more motivated to engage in activities.
B. Arrange a meeting with the family to discuss the client's situation. While family involvement is important, it is not the first priority. Immediate care interventions are needed to address the client’s current needs.
C. Assess the client's ability to communicate with the other staff members. While communication is important, the priority is to address the client’s physical and emotional needs by establishing a routine.
D. Administer the client's antidepressant medication as prescribed. Medication management is crucial, but the first step is to engage the client in a structured routine to help them begin functioning.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

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?

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?