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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.

Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.

Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.

Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.

Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.

A. Do not eat or drink for 12 hours prior to the test. B. Eliminate all dietary cholesterol for one week before this test. C. Avoid caffeinated beverages for several days prior to the test. D. Stop eating eggs and drinking milk for two days before the test.

Correct Answer is A

Explanation

Do not eat or drink for 12 hours prior to the test. This is because fasting is required for a total serum cholesterol test to get accurate results. Fasting means not eating or drinking anything except water for 9 to 12 hours before the test.

Choice B is wrong because eliminating all dietary cholesterol for one week before the test is not necessary and will not affect the test results. Dietary cholesterol only accounts for a small portion of the total cholesterol in the blood.

Choice C is wrong because avoiding caffeinated beverages for several days prior to the test is not required and will not influence the test results. Caffeine does not affect cholesterol levels.

Choice D is wrong because stopping eating eggs and drinking milk for two days before the test is not needed and will not change the test results. Eggs and milk contain cholesterol, but they also have other nutrients that may lower the risk of heart disease.

Normal ranges for total serum cholesterol are less than 200 mg/dL (5.18 mmol/L) for adults. Higher levels may indicate an increased risk of heart disease and stroke.

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Which client should a nurse evaluate first on a surgical unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?

Correct Answer is D

Explanation

A client is scheduled for a “total serum cholesterol” lab test. Which instruction to the client should be discussed to ensure adequate preparation for the test?

Correct Answer is A

Explanation

A client has been recently started on phenelzine, a monoamine oxidase inhibitor (MAOI) for depression. Which statement indicates that the client requires further educational reinforcement about the medication?

A community health nurse is teaching a group of older adults about risk factors for a hip fracture. What statements indicate a correct understanding of these risk factors? Select all that apply.

A client has undergone a surgical procedure and develops a weak, rapid pulse. Which intervention should the nurse recommend to provider during their SBAR communication?

Which nursing action is most important after administering nitroglycerin sublingually?

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

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

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?