A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Encourage ambulation only after 48 hours post-surgery.

Instruct clients to avoid coughing to prevent wound dehiscence.

Monitor for signs of infection, such as fever or redness.

Remove surgical dressings within 12 hours post-surgery.

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging ambulation only after 48 hours delays recovery, as early ambulation (within 12-24 hours) promotes circulation, prevents thromboembolism, and aids bowel function post-abdominal surgery. This instruction is incorrect, as it contradicts evidence-based protocols for early mobilization to enhance recovery.
Choice B reason: Instructing clients to avoid coughing is inappropriate, as coughing and deep breathing prevent pulmonary complications like atelectasis post-abdominal surgery. Splinting the incision during coughing reduces discomfort and dehiscence risk, making this instruction incorrect as it increases respiratory complications.
Choice C reason: Monitoring for signs of infection, such as fever or redness, is critical post-abdominal surgery to detect complications early. Infections can delay healing and lead to sepsis. Regular assessment ensures timely intervention, aligning with evidence-based postoperative care, making this the correct information to include.
Choice D reason: Removing surgical dressings within 12 hours is not standard, as dressings typically remain for 24-48 hours or per surgeon orders to protect the wound and reduce infection risk. Premature removal increases contamination risk, making this instruction incorrect for postoperative care.

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

Explanation

Choice A reason: Hypothermia increases metabolic demand in newborns, depleting glucose stores rapidly. Neonates have limited glycogen reserves, and cold stress accelerates glucose use for thermogenesis, risking hypoglycemia. This is critical in nurseries, as thermoregulation is essential to prevent metabolic imbalances in vulnerable infants.
Choice B reason: Thrombocytopenia, low platelet count, affects clotting, not glucose metabolism. It may occur in sepsis but does not directly cause hypoglycemia. Glucose regulation depends on liver function and insulin balance, not platelets, making this irrelevant to hypoglycemia risk in newborns.
Choice C reason: Prematurity heightens hypoglycemia risk due to immature liver glycogen stores and limited gluconeogenesis. Preterm infants have high metabolic demands and low reserves, increasing susceptibility to low blood glucose, necessitating close monitoring and early feeding to stabilize glucose levels.
Choice D reason: Anemia, low red blood cell count, impacts oxygen delivery but not glucose metabolism directly. Severe anemia may increase metabolic stress, but it is not a primary hypoglycemia cause. Glucose regulation relies on hepatic and insulin functions, not hematologic status, in newborns.
Choice E reason: Maternal diabetes causes fetal hyperinsulinemia from maternal hyperglycemia, leading to neonatal hypoglycemia post-birth. Excess insulin depletes glucose stores after umbilical cord clamping, as maternal glucose supply ceases, making this a critical risk factor requiring vigilant monitoring in newborns.

A. Administer supplemental oxygen. B. Have the client sit down. C. Check the client’s vital signs. D. Notify the provider immediately.

Correct Answer is B

Explanation

Choice A reason: Administering oxygen is premature without assessing the cause of chest heaviness. While hypoxia may occur in aneurysm rupture, stopping exertion reduces cardiovascular demand first, prioritizing safety in a client with an abdominal aortic aneurysm at risk for rupture.
Choice B reason: Having the client sit down is the priority, as chest heaviness may signal aneurysm instability. Rest reduces aortic wall stress and oxygen demand, preventing rupture or dissection, stabilizing the client for further assessment and intervention in this high-risk condition.
Choice C reason: Checking vital signs is important but secondary to stopping exertion. Chest heaviness suggests potential aneurysm rupture, and continued ambulation risks catastrophe. Sitting the client minimizes cardiovascular stress, allowing subsequent vital sign checks to guide further actions effectively.
Choice D reason: Notifying the provider is critical but not first. Chest heaviness requires immediate cessation of activity to reduce aortic pressure. Sitting stabilizes the client, allowing data collection (e.g., vital signs) before provider notification, ensuring urgent intervention for potential aneurysm complications.

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A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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