Which client should a nurse evaluate first on a surgical unit?
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”.
A two-day postoperative client who has bile-colored fluid draining from his nasogastric tube and says, “I feel like I might vomit.”.
A three-day postoperative client who has an ileostomy and reports the need to have a bowel movement.
A three-day postoperative client who is receiving intravenous antibiotics for a wound infection.
The Correct Answer is A
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
120/77 mmHg. This is because this blood pressure reading is within the normal range of less than 120/80 mmHg. Hypertension is defined as a blood pressure of 140/90 mmHg or higher.
Choice A is wrong because 84/50 mmHg is too low and may indicate hypotension, which can cause dizziness, fainting, or shock.
Choice C is wrong because 148/88 mmHg is above the normal range and indicates prehypertension, which is a risk factor for developing hypertension and cardiovascular disease.
Choice D is wrong because 160/90 mmHg is above the normal range and indicates stage 1 hypertension, which requires treatment with lifestyle changes and medication.
Correct Answer is B
Explanation
This is because offering fluids that the client likes and in small amounts can help increase the client’s fluid intake and prevent dehydration. According to, some other nursing measures that can help improve the client’s nutritional intake are:
- Encouraging favorite foods from home, when possible.
- Providing frequent oral hygiene.
- Providing a pleasant environment during mealtime.
- Providing assistance with eating, if needed.
Choice A is wrong because placing a freshwater pitcher on the bedside table may not be enough to motivate the client to drink more fluids, especially if the client does not like plain water or has difficulty reaching for the pitcher.
Choice C is wrong because explaining the problems of inadequate intake may not be effective in changing the client’s behavior, and may even cause anxiety or resentment.
Choice D is wrong because stressing the importance of drinking fluids may also be ineffective or counterproductive, as it may sound like nagging or lecturing to the client.
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