Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

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 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 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 client is currently resting in bed.

Answer and Explanation

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

• Incision dressing is dry and intact, with no bleeding: Indicates proper wound healing and absence of complications such as infection or hemorrhage. A clean, dry surgical site is a key criterion for safe discharge.

• Tolerated clear liquids and advanced to soft diet: Shows that the gastrointestinal system is functioning post-anesthesia and surgery. Tolerance of oral intake without nausea, vomiting, or abdominal discomfort is essential before discharge.

• Ambulated around the unit and tolerated activity well: Demonstrates that the client has regained baseline mobility, which reduces risk of postoperative complications like atelectasis or DVT. Ability to mobilize is a standard requirement for safe discharge.

• Bowel sounds present in all four quadrants; passing flatus: Confirms the return of peristalsis and bowel function, which is necessary before discharge after abdominal surgery. Passing gas is an expected milestone indicating GI recovery.

• Pain controlled with oral analgesia: Suggests that the client’s pain is manageable without IV medication. Effective pain control at home using oral medications supports comfort and reduces the risk of readmission.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Procure platelet products from the blood bank: Retrieving blood products is a task that falls within the scope of a UAP's responsibilities, as it is non-invasive and does not require clinical decision-making. It supports patient care without requiring specialized assessment or judgment.

B. Evaluate a client's mobility progress toward the plan of care: Evaluation of a client’s progress requires clinical judgment and is within the scope of a licensed nurse. A UAP is not trained to interpret clinical outcomes or compare them against the plan of care.

C. Determine the diameter and depth of a client's dermal ulcer: This task involves clinical assessment skills and interpretation of findings, which must be performed by a licensed nurse. UAPs are not qualified to measure or assess wounds at this level.

D. Titrate oxygen to the prescribed parameters: Adjusting oxygen delivery based on clinical assessments is a complex intervention requiring nursing judgment. Titration decisions must be made by licensed personnel to ensure safe and effective oxygen therapy.

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

Explanation

• Condition: Hypotension is a known side effect of epidural anesthesia is hypotension due to sympathetic nervous system blockade, which leads to peripheral vasodilation. This can reduce blood return to the heart, lowering cardiac output and maternal blood pressure.

• Peripheral vasodilation: Epidural anesthesia causes sympathetic blockade, resulting in peripheral vasodilation, venous pooling, and a potential drop in maternal blood pressure. This is the primary physiological mechanism behind epidural-induced hypotension.

Rationale for Incorrect Options:

• Inadequate pain relief: Epidural anesthesia is typically highly effective for labor pain when properly administered. There is no indication in the notes of breakthrough pain or poor anesthetic placement, so this is not the primary concern at this stage.

Fluid overload: While IV fluids are administered with an epidural to reduce the risk of hypotension, the infusion rate of 75 mL/hr is not excessive. There are no signs such as edema, crackles, or elevated blood pressure to suggest fluid overload.

• Urinary retention: Epidurals can cause decreased sensation in the bladder, leading to retention, but the question directs attention to the physiological effects of the epidural itself, making hypotension a more critical risk based on vasodilation.

• Decreased fetal heart rate: Fetal bradycardia can occur secondary to maternal hypotension, but it's a consequence rather than a direct client finding for this case. The FHR remains within normal limits, suggesting no current distress.

• Full urinary bladder: This may occur later with epidural anesthesia due to reduced bladder sensation. However, there's no current evidence in the case data of bladder distension or delayed voiding.

• Inability to push: This may occur during the second stage of labor if motor block is excessive, but the client is currently in early labor and not yet pushing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is A

Explanation

Exhibits select from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown

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

Explanation

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

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?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

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?

Exhibits Select the 4 assessment findings that require immediate follow up.

Exhibits Choose the most likely options missing from the statements by selecting from the list of options provided. The nurse teaches the client about the fetus reactions to labor by dropdown . The nurse will assess the fetus reaction by dropdown.