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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Inability to concentrate is a common symptom of hypoglycemia in type 1 diabetes, as low blood glucose impairs brain function, leading to confusion and difficulty focusing. This neuroglycopenic symptom results from insufficient glucose for cerebral energy, making it a critical indicator requiring prompt intervention like glucose administration.
Choice B reason: Polydipsia is associated with hyperglycemia, not hypoglycemia, in type 1 diabetes. It results from osmotic diuresis due to high blood glucose, causing dehydration and thirst. This symptom does not indicate low blood sugar, making it incorrect for identifying hypoglycemia in this scenario.
Choice C reason: Tremors are a hallmark of hypoglycemia, caused by the sympathetic nervous system’s response to low blood glucose, triggering catecholamine release. This leads to shakiness, a common adrenergic symptom, signaling the need for immediate glucose to restore normal levels, making it a correct indicator.
Choice D reason: Acetone breath odor is linked to diabetic ketoacidosis (DKA), a complication of hyperglycemia, not hypoglycemia. It results from ketone production during fat metabolism in uncontrolled diabetes. This finding is irrelevant to low blood sugar, making it incorrect for this scenario.
Choice E reason: Diaphoresis, or excessive sweating, is a classic hypoglycemia symptom due to autonomic activation from low blood glucose. The body releases adrenaline, causing sweating as a stress response. This reliable indicator prompts urgent treatment to prevent severe complications, making it a correct choice.
Correct Answer is D
Explanation
Choice A reason: Stating immunizations are required for air travel is inaccurate, as no such mandate exists for infants. This response does not address the parents’ concerns or educate them, potentially alienating them, making it ineffective and incorrect for fostering dialogue about immunization.
Choice B reason: Offering a referral to an infectious disease provider is premature and does not directly address the parents’ decision. Education and discussion are needed first to understand their concerns, making this response less effective and inappropriate as an initial approach.
Choice C reason: Suggesting no need to immunize against rare diseases is misleading, as vaccines prevent resurgences (e.g., measles). This undermines public health and dismisses the parents’ concerns, making it incorrect and potentially harmful to the infant’s health.
Choice D reason: Inviting discussion about the parents’ knowledge fosters open, non-judgmental communication, allowing the nurse to address misconceptions and provide evidence-based information. This therapeutic approach builds trust and encourages informed decision-making, making it the correct response for vaccine hesitancy.
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