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The nurse is caring for a client with a diagnosis of a ruptured appendix who underwent an emergency exploratory laparotomy with appendectomy 48 hours ago.

The 55-year-old client was admitted through the Emergency Department (ED) with fever, chills, nausea, and diﬀuse abdominal pain. Computed tomography (CT) of the abdomen confirmed a ruptured appendix with widespread inﬂammation. The client is 6'1" (193.04 cm) tall and weighs 260 lbs (117.93 kg). The client is obese with a BMI of 31.6 kg/m2. The client underwent an immediate exploratory laparotomy with appendectomy. The wound was not closed and was packed with sterile gauze.

The client's past medical history includes gastric reﬂux disease (GERD), hypertension, and type 2 diabetes mellitus. The client has no known drug allergies (NKDA). Home medications include lisinopril 20 mg 1 tablet PO every day, omeprazole 40 mg 1 capsule PO every day, metformin ER (extended-release) 750 mg 1 tablet PO every day, and acetaminophen 325 mg 2 tablets PO every 4 hours PRN for pain.

The physician is notified of the change in the client's wound. The nurse receives orders to obtain blood cultures x 2 and a culture of the wound now. The nurse prepares to change the client’s abdominal dressing and obtain a wound culture.

Which steps are appropriate for this procedure? (Select all that apply.)

Wear sterile gloves to pack the wound.

Clean the skin around the wound with non-sterile 4x4 gauze.

Don an eye shield before irrigating the wound.

Use alcohol-based hand sanitizer between glove changes.

Pour sterile normal saline into a sterile irrigation tray.

Obtain a wound culture before the wound bed is irrigated.

Cover the irrigated packing with an ABD pad.

Assess pain prior to starting the procedure.

Wear sterile gloves to remove the old dressing.

Answer and Explanation

Correct Answer : A,C,E,F,G,I

a) It is important to wear sterile gloves when packing the wound to prevent the introduction of new bacteria into the wound.
c) Donning an eye shield protects the nurse from splash-back or aerosolized particles during irrigation.
e) Sterile normal saline should be used for irrigation to prevent introducing new bacteria to the wound. It should be poured into a sterile irrigation tray.
f) A wound culture should be obtained before the wound bed is irrigated to prevent diluting the specimen with irrigation solution.
g) After irrigating the wound and packing it with sterile gauze, the packing should be covered with an ABD pad to protect the wound and prevent contamination.
h) Assessing pain prior to starting the procedure is important to establish a baseline for pain management and to monitor the client's response to the procedure.
i) Sterile gloves should be worn when removing the old dressing to prevent introducing new bacteria to the wound.
b) Cleaning the skin around the wound with non-sterile gauze is not appropriate as it can introduce new bacteria to the wound.
d) Alcohol-based hand sanitizer is not a substitute for hand washing and should not be used between glove changes as it does not eﬀectively remove all bacteria from the hands.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

Choice A: Cream is not allowed on a clear liquid diet because it contains fat and protein, which make it opaque.
Choice B:While plain gelatin is allowed, applesauce is not because it is a puréed/semi-solid food, not a clear liquid.
Choice C:Clear fruit juices without pulp (such as apple juice, cranberry juice, and white grape juice) are permitted.
Choice D:Broth or bouillon is considered a clear liquid, as long as it does not contain solid particles.
Choice E:Tea is a clear liquid, and sugar does not change its clarity.

Choice F:Ice pops made from clear liquids (such as fruit juice without pulp) are permitted.

A. The nurse provides written and verbal instructions prior to discharge. When at home the client began to take the wrong medication. B. The nurse hangs a new bag of IV ﬂuids 1 hour early and does not count what is remaining in the bag on the ﬂuid record. C. The nurse gives medication to another nurse to give to a client and the wrong client receives the medication and becomes ill. D. A client becomes confused and combative and pulls out the IV. The nurse calls the health care provider to change the behavior.

Correct Answer is C

Explanation

Negligence is a failure to act in a reasonable and prudent manner that results in harm or injury to another person. In option c), the nurse did not exercise reasonable care in ensuring that the medication was given to the correct patient, which resulted in harm to the wrong patient.

The other options (a, b, and d) do not involve a failure to act in a reasonable and prudent manner that caused harm or injury to the client. In option a), the nurse provided written and verbal instructions, but the client did not follow them, which is beyond the nurse's control.

In option b), the nurse made an error in documenting the ﬂuid count, which is a documentation error, not negligence. In option d), the nurse acted appropriately by calling the healthcare provider to change the client's behavior, and the situation does not involve negligence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a clear liquid diet. The nurse removes which item from the client's tray? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

In which situation is the nurse determined to be negligent?

Correct Answer is C

Explanation

The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

While the nurse prepares an injection for a client, the needle cap falls on the ﬂoor. Which action indicates that the injection will be sterile?

A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?