Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Increase the client’s intake of Vitamin C.

Teach the client to splint the incision when coughing.

Have the client do abdominal exercises.

Perform passive range of motion exercises.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

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Correct Answer is B

Explanation

Choice A reason: Effective coughing after medication administration is not specifically required for the use of metered dose inhalers like albuterol and beclomethasone. While coughing can help clear mucus from the airways, it is not a necessary step in the administration of these medications. The primary focus should be on proper inhaler technique to ensure the medication reaches the lungs effectively.

Choice B reason: Rinsing the mouth after beclomethasone administration is crucial. Beclomethasone is an inhaled corticosteroid, and rinsing the mouth helps prevent oral thrush, a common side effect of inhaled steroids. Thrush is a fungal infection that can develop in the mouth and throat due to the residue of the medication. Proper rinsing and spitting out the water can significantly reduce the risk of this infection.

Choice C reason: Using beclomethasone as needed when breathing normally is incorrect. Beclomethasone is a maintenance medication that should be used regularly as prescribed, not on an as-needed basis. It helps control chronic inflammation in the airways and prevent asthma symptoms. Using it only when symptoms are not present would not provide the consistent anti-inflammatory effect needed to manage asthma effectively.

Choice D reason: Taking the beclomethasone first, followed by the albuterol, is incorrect. The correct sequence is to use the albuterol first. Albuterol is a bronchodilator that works quickly to open up the airways, making it easier for the beclomethasone to reach deeper into the lungs and be more effective

A. Lung sounds are clear bilaterally, both anterior and posterior. B. Peak expiratory flow rate readings are in the green zone. C. Client reports shortness of breath when engaging in exercise. D. There were three occurrences of asthma exacerbations in the past month.

Correct Answer is B

Explanation

Choice A reason: Lung sounds being clear bilaterally, both anterior and posterior, is a positive sign and indicates that there are no immediate obstructions or significant inflammation in the airways. However, it does not provide a comprehensive measure of asthma control over time. Asthma control is better assessed through objective measures like peak expiratory flow rate (PEFR) readings.

Choice B reason: Peak expiratory flow rate (PEFR) readings in the green zone indicate that the client’s asthma is well-controlled. The green zone typically represents 80-100% of the client’s personal best PEFR, suggesting that their airways are open and they are not experiencing significant bronchoconstriction. Regular monitoring of PEFR helps in assessing the effectiveness of the asthma management plan and making necessary adjustments to prevent exacerbations.

Choice C reason: Reporting shortness of breath when engaging in exercise suggests that the client’s asthma may not be fully controlled. Exercise-induced bronchoconstriction is a common issue in asthma, and experiencing symptoms during physical activity indicates that the current medication regimen may need adjustment.

Choice D reason: Having three occurrences of asthma exacerbations in the past month indicates poor asthma control. Frequent exacerbations suggest that the client’s asthma is not well-managed and that their medication regimen may need to be reviewed and adjusted.

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Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with asthma. The therapeutic regimen using metered dose inhalers includes albuterol 2 puffs and beclomethasone 2 puffs. The nursing plan of care must include teaching regarding:

Correct Answer is B

Explanation

The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

Correct Answer is B

Explanation

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