The nurse is changing a client’s abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?

Apply an iodine-soaked sterile dressing.

Irrigate the wound and apply a dry sterile dressing.

Apply a dressing and notify the surgeon.

Apply a sterile dressing soaked with normal saline.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Applying an iodine-soaked sterile dressing is not the best initial action. Iodine can be irritating to exposed tissues and may not provide the necessary moisture to protect the underlying tissue. The primary goal is to keep the tissue moist and prevent further damage.

Choice B Reason:

Irrigating the wound and applying a dry sterile dressing is not appropriate in this situation. Irrigation might cause further damage to the exposed tissue, and a dry dressing will not keep the tissue moist, which is crucial for preventing desiccation and promoting healing.

Choice C Reason:

Applying a dressing and notifying the surgeon is important, but the type of dressing is crucial. A dry dressing or an inappropriate dressing material can harm the exposed tissue. The nurse should first apply a moist dressing to protect the tissue and then notify the surgeon.

Choice D Reason:

Applying a sterile dressing soaked with normal saline is the most appropriate initial action. This type of dressing keeps the exposed tissue moist, which is essential for preventing further damage and promoting healing. Normal saline is gentle and will not irritate the tissue, making it the best choice for initial wound care.

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Correct Answer is A

Explanation

Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.

Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.

Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.

Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.

A. The client will demonstrate decreased episodes of coughing at night. B. The client’s pulse oximetry values will remain above 94% on room air for the majority of the time. C. The client’s breath sounds will only have slight wheezing by discharge. D. The client will correctly demonstrate the use of a peak flow meter.

Correct Answer is B

Explanation

Maintaining adequate oxygenation is the primary goal for a client with impaired gas exchange due to an asthma exacerbation. Pulse oximetry is a non-invasive method to monitor the oxygen saturation of a patient’s blood, and values above 94% indicate sufficient oxygenation.

Choice A reason:

The client will demonstrate decreased episodes of coughing at night is important but not the priority goal. While reducing coughing can improve comfort and sleep quality, it does not directly address the critical issue of impaired gas exchange. The primary concern in an asthma exacerbation is ensuring that the client maintains adequate oxygen levels.

Choice B reason:

The client’s pulse oximetry values will remain above 94% on room air for the majority of the time is the priority goal. This goal directly addresses the issue of impaired gas exchange by ensuring that the client maintains adequate oxygenation. Pulse oximetry values above 94% indicate that the client’s blood is sufficiently oxygenated, which is crucial for preventing hypoxemia and ensuring that the body’s tissues receive enough oxygen to function properly.

Choice C reason:

The client’s breath sounds will only have slight wheezing by discharge is a relevant goal but not the priority. While reducing wheezing is an indicator of improved airway function, it is not as directly measurable or critical as maintaining adequate oxygen saturation. Wheezing can persist even when oxygen levels are adequate, so it is not the most reliable indicator of improved gas exchange.

Choice D reason:

The client will correctly demonstrate the use of a peak flow meter is an important educational goal but not the priority in an acute setting. Proper use of a peak flow meter can help the client monitor their asthma and prevent future exacerbations, but it does not directly address the immediate issue of impaired gas exchange. The priority in an acute asthma exacerbation is to ensure that the client is adequately oxygenated.

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The nurse is changing a client’s abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the client and notes fine crackles throughout the lungs bilaterally. This assessment finding is often associated with:

Correct Answer is A

Explanation

The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?

Correct Answer is B

Explanation

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