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 A

Explanation

A. Position bedside table so the client can lean across it. Clients with pancreatitis often find relief from pain by sitting up and leaning forward. This position helps alleviate the pressure on the pancreas and can reduce pain.

B. Raise head of bed to a 90-degree angle. Raising the bed too high may increase discomfort for clients with pancreatitis. The more comfortable position is typically sitting up but leaning forward.

C. Encourage rest until the analgesic becomes effective. While rest is important, positioning the client to alleviate pain should take priority in this situation.

D. Place bed in a reverse Trendelenburg position. This position is typically used for patients with cardiovascular or abdominal issues but is not the most effective for managing pancreatitis pain.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Pain relief: One of the primary goals and indications of effective epidural anesthesia is significant reduction or elimination of pain associated with labor contractions, as reflected in the patient asking for and receiving the epidural to manage increasing pain levels.

Progression of labor: Effective epidural anesthesia should allow the labor to progress without adding undue stress or causing significant delays. Monitoring cervical dilation and effacement as well as the baby's descent (station) helps determine if labor is progressing normally even after epidural administration.

Vital signs: Stable vital signs are important indicators that the epidural anesthesia is not causing adverse effects such as severe hypotension or bradycardia, which can sometimes occur with regional anesthesia due to the blockade of sympathetic nerves. Regular monitoring and stability of these signs are crucial for demonstrating effective and safe epidural anesthesia management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.