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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Insulin regular (Humulin-R) is the only form of insulin that is safe for intravenous administration. This is because it is a short-acting insulin that has a rapid onset and peak time, and does not contain any additives or suspensions that could interfere with the infusion.

Choice A is wrong because insulin aspart (Novo Log) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

Choice B is wrong because insulin glargine (Lantus) is a long-acting insulin that covers insulin needs for about a full day. It is not suitable for intravenous use because it forms micro-precipitates under the skin that release insulin slowly and steadily.

Choice C is wrong because insulin lispro (Humalog) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

A. Decreased blood pressure. B. Increased temperature. C. Impaired physical coordination. D. Nausea and appetite loss. E. Respiratory depression.

Correct Answer is ["A","C","E"]

Explanation

Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.

Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.

Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.

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Which action is essential when assessing for drainage in a client with a large abdominal wound?

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Naxlex Comprehensive Predictor Exams

A client who has a blood glucose level of 800 mg/dL is to receive insulin intravenously. Which form of insulin is safe for intravenous administration?

Correct Answer is D

Explanation

The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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