The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Cover the bowel with wet sterile gauze

Assist the client into a low-Fowler's position with knees flexed

Assist the client into a side-lying position with knees flexed

Retrieve the crash cart from the nursing station

Call for assistance

Measure the client's inspiratory volume via incentive spirometer

Answer and Explanation

Correct Answer : A,B,E

A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.

B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.

C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.

D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.

E: Calling for assistance is essential to notify the surgical or medical team promptly.

F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.

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Correct Answer is A

Explanation

A. PCA pumps allow clients to self-administer pain medication within prescribed limits when experiencing pain.

B. Doses are controlled by a lockout mechanism to prevent overdosing.

C. PCA pumps deliver medication as needed, not a continuous infusion unless programmed otherwise.

D. The client independently determines when to use the PCA within prescribed parameters.

A. Assess the surgical dressing, noting presence and character of drainage. B. Assess urinary output and presence of bladder distention. C. Assess blood pressure and the estimated blood loss during surgery. D. Assess for airway patency and quality of respirations.

Correct Answer is D

Explanation

A. Checking the surgical dressing is important but not as urgent as ensuring respiratory function.

B. Assessing urinary output is necessary but secondary to airway patency.

C. Monitoring blood pressure and blood loss is important but less critical than respiratory status.

D. Airway patency is the highest priority in the immediate postoperative period to prevent respiratory failure.

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The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client on patient-controlled analgesia (PCA) pump. Which statement made by the client is correct?

Correct Answer is A

Explanation

Which is the priority intervention for the nurse to perform in the post anesthesia care unit (PACU)?

Correct Answer is D

Explanation

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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

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A nurse is caring for several clients in the post-operative unit. Which client should the nurse see first?

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