Which action is essential when assessing for drainage in a client with a large abdominal wound?
Feel the top of the client’s legs.
Examine area underneath the client.
Ask the client to cough forcefully.
Have the client sit up and lean forward.
The Correct Answer is B
This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.
Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.
Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.
Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.
Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“My medication will be given at the scheduled times to best manage my pain.” This statement demonstrates understanding of the pain management plan because it shows that the client knows the importance of preventing pain from becoming severe by taking medication regularly. Scheduled administration of analgesics is more effective than administering them on demand.
Choice A is wrong because it implies that the client will wait until the pain is severe before asking for medication, which can make it harder to control.
Choice C is wrong because it suggests that the client expects to receive inadequate pain relief due to their history of opioid abuse, which is not ethical or evidence-based.
Choice D is wrong because it indicates that the client believes they will be denied any narcotics for pain, which is also not ethical or
evidence-based. Clients with a history of opioid abuse can still receive opioids for acute pain, but they may need higher doses or more frequent administration to achieve adequate analgesia.
Normal ranges for vital signs are as follows: respiratory rate 12-20 breaths per minute, heart rate 60-100 beats per minute, blood pressure 120/80 mmHg, temperature 36.5-37.5°C (97.7- 99.5°F).
Correct Answer is ["A","E"]
Explanation
Olanzapine is an antipsychotic drug that can cause weight gain and increased blood sugar as common side effects.
Therefore, the nurse should monitor the client’s weight and blood sugar regularly to prevent complications such as obesity and diabetes.
Choice B is wrong because olanzapine does not affect skin turgor, which is a measure of hydration status.
Choice C is wrong because olanzapine does not cause falls, although it may cause dizziness or unsteadiness as side effect.
Choice D is wrong because olanzapine does not cause significant changes in blood pressure, although it may cause orthostatic hypotension (a drop in blood pressure when standing up) as a side effect.
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