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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.

Notify the surgeon

Place the client in low-Fowler's with knees raised

Start a peripheral IV (PIV)

Cover the wound with moistened sterile gauze

Hold pressure on the dressing

Encourage the client to drink fluids

Assist the client to cough and deep breathe

Answer and Explanation

Correct Answer : A,C,D

A. Notify the surgeon: The client has developed a wound dehiscence with evisceration of intestinal tissue, which is a serious surgical complication. Immediate communication with the surgeon is necessary to determine the next steps for repair and to avoid further complications, such as infection or organ injury.

B. Place the client in low-Fowler's with knees raised: While positioning is important for comfort and reducing pressure on the abdomen, placing the client in low-Fowler’s position is not the priority. The focus should be on protecting the eviscerated tissue and managing potential hypovolemia.

C. Start a peripheral IV (PIV): Starting a PIV is essential for administering fluids and medications, especially if the client requires resuscitation or further surgical intervention. The client's vital signs (decreased blood pressure, increased heart rate) suggest potential hypovolemia or shock, which may require IV fluids for stabilization.

D. Cover the wound with moistened sterile gauze: Evisceration requires immediate intervention to protect the exposed tissue. The nurse should cover the wound with sterile gauze that is moistened with normal saline to prevent the exposed intestines from drying out and to reduce the risk of infection. This is a critical step in managing the wound before further surgical intervention.

E. Hold pressure on the dressing: Applying pressure to the surgical dressing is not appropriate in this situation because it could cause more harm or further disrupt the wound. The wound should be covered with moistened sterile gauze to protect the eviscerated tissue, not pressured.

F. Encourage the client to drink fluids: Oral intake is not appropriate in the acute post-surgical phase when the client has experienced evisceration. The client may require surgical repair, and fluids should be administered intravenously to avoid the risk of aspiration or bowel perforation.

G. Assist the client to cough and deep breathe: While respiratory exercises are important for preventing atelectasis and pneumonia post-operatively, they are not an immediate priority in this situation where the client has evisceration. Stabilizing the wound and addressing potential shock takes precedence.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Exenatide does not act exactly the same as insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist, not insulin.

B. Notify your healthcare provider if you start having abdominal pain is important because abdominal pain is a known side effect of exenatide and may indicate a more serious issue like pancreatitis, which needs to be addressed promptly.

C. There are precautions when taking exenatide with other medications, especially those that affect gastrointestinal motility or glucose levels, so this statement is incorrect.

D. Exenatide should be injected within 60 minutes before a meal, not 30 minutes before or after, to optimize its effectiveness.

A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. B. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. C. Don an N95 respirator mask, face shield, gown, gloves, and shoe coverings prior to returning to the room. D. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.

Correct Answer is C

Explanation

A: Notifying the charge nurse is important but secondary to immediately donning appropriate PPE for direct patient care.

B: Explaining the client’s exposure is helpful, but it does not prioritize the nurse’s own safety and infection control.

C: Wearing full PPE, including an N95 mask, is essential for protecting the nurse and others from COVID-19 transmission, especially with a symptomatic client who may be contagious.

D: Teaching the client about prevention is important but not the immediate priority when entering a potentially infectious environment.

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Patient Data Exhibits Which should the nurse immediately do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.