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 C
Explanation
Choice A reason: Asking parents to wait outside may increase the preschooler’s anxiety, as parental presence provides comfort. Unless clinically necessary, excluding parents is not ideal, so this action is inappropriate for preparing the child, making it incorrect.
Choice B reason: Teaching deep-breathing to a preschooler is challenging due to their developmental stage, and it may not effectively reduce anxiety for a dressing change. Simpler reassurance is more suitable, so this is less effective, making it incorrect.
Choice C reason: Explaining the procedure in simple terms helps the preschooler understand what to expect, reducing fear and promoting cooperation. This developmentally appropriate approach aligns with pediatric care principles, making it the correct action for preparation.
Choice D reason: Limiting teaching to 20 minutes is impractical for a preschooler, whose attention span is short. Brief, simple explanations are more effective, and prolonged sessions may overwhelm the child, so this is incorrect for preparing them.
Correct Answer is C
Explanation
Choice A reason: Avoiding physical exercise is not recommended for multiple sclerosis, as moderate activity like walking or stretching improves muscle strength, balance, and fatigue management. Complete avoidance leads to deconditioning, worsening mobility and fatigue, which are common in MS, making this instruction counterproductive to symptom management.
Choice B reason: Taking hot baths is not advised for multiple sclerosis, as heat can exacerbate symptoms like fatigue and muscle weakness due to temperature sensitivity (Uhthoff’s phenomenon). Cool or lukewarm baths are safer, supporting symptom control, making this instruction harmful and inappropriate for MS management.
Choice C reason: Performing daily stretching exercises improves flexibility, reduces spasticity, and enhances mobility in multiple sclerosis. Stretching strengthens muscles and prevents contractures, supporting functional independence. This aligns with evidence-based MS management to mitigate symptoms and improve quality of life, making it the correct instruction.
Choice D reason: Limiting fluid intake to reduce bladder irritation is inappropriate, as adequate hydration (2-3 L/day) prevents urinary tract infections, common in MS due to bladder dysfunction. Fluid restriction can worsen symptoms and dehydration, making this instruction incorrect for managing MS-related bladder issues effectively.
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