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 D

Explanation

A. Hyperthermia is not commonly associated with diazepam.

B. Hypertension is not a common concern with diazepam use.

C. Tachycardia is not a significant side effect of diazepam.

D. Respiratory depression is the most serious and potentially life-threatening side effect of diazepam, requiring close monitoring.

A. “I have the ability to self-dose when experience pain." B. “I can receive a dose as often as need with this pump.” C. “I’ll receive a steady flow of medication to control my pain.” D. "I will decide with the nurse when I should receive a dose."

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.

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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 client is receiving diazepam prior to a procedure. Which side effect should the nurse be most concerned about?

Correct Answer is D

Explanation

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

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]

A nurse is scheduling an older client for a surgical clearance appointment. Which intervention is best to reduce the risk of drug interactions for the client?

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.)

A nurse is teaching a newly licensed nurse about anesthesia. The nurse should include that an epidural is an example of which of the following types of anesthesia?

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A nurse is caring for a client who is scheduled for a surgical procedure. 3 Exhibits The nurse is reviewing the client's electronic medical record. Which of the following findings places the client at risk for a surgical complication? Select all that apply.

The nurse is providing preoperative teaching. The client states, "I'm so nervous about my surgery". What is the best response by the nurse?

A nurse is caring for a client who has returned to the unit on a stretcher following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?