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
Potassium is 3.0.
This is because furosemide is a loop diuretic that can cause hypokalemia (low potassium levels) as a side effect. Hypokalemia can lead to muscle weakness, cramps, cardiac arrhythmias, and digoxin toxicity. The normal range for potassium is 3.5 to 5.0 mEq/L.
Choice A is wrong because sodium is 144 is within the normal range of 135 to 145 mEq/L.
Choice C is wrong because chloride is 99 is within the normal range of 98 to 106 mEq/L.
Choice D is wrong because calcium is 5.0 is within the normal range of 4.5 to 5.5 mg/dL.
Correct Answer is C
Explanation
Orthostatic hypotension noted with dangling.
This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.
The nurse should document this finding and report it to the physician.
Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.
Choice B is wrong because the gait belt applied is not a finding but an intervention.
Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.
Choice E is wrong because spot accucheck obtained is not a finding but an action.
Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.
Choice G is wrong because provided reassurance is not a finding but a nursing measure.
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