A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

Prepare the client to return to the operating room.

Obtain a sample of the drainage to send to the lab.

Bring additional sterile dressing supplies to the room.

Auscultate the abdomen for bowel sound activity.

Answer and Explanation

The Correct Answer is A

A. Prepare the client to return to the operating room:
This is the correct and immediate priority. Evisceration, where internal organs protrude through the surgical incision, is a surgical emergency. Returning the client to the operating room is necessary to assess the extent of the complication, address the wound dehiscence, and protect the exposed organs. This intervention aims to prevent further complications and provide necessary surgical interventions.

B. Obtain a sample of the drainage to send to the lab:
While obtaining samples for laboratory analysis can be important for infection control, in the context of a client with evisceration, the primary concern is the surgical emergency. The priority is to address the wound complication by returning to the operating room rather than focusing on laboratory analysis at this immediate moment.

C. Bring additional sterile dressing supplies to the room:
While bringing additional supplies may be necessary, the priority in this situation is to prepare for the client's return to the operating room. Once the client is in a controlled surgical environment, additional dressing changes and wound care can be performed as needed.

D. Auscultate the abdomen for bowel sound activity:
While monitoring bowel sounds is a routine nursing assessment, in the context of evisceration, the immediate concern is the exposure of internal organs and the risk of infection. Preparing for the operating room takes precedence over routine assessments.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Carefully cleans and peels all fresh fruit and vegetables:
While cleaning and peeling fresh fruits and vegetables may contribute to food safety, it is not a specific indication of adherence to the DASH eating plan.

B. Uses only lactose-free dairy products:
The DASH eating plan encourages the consumption of low-fat or fat-free dairy products. Using lactose-free dairy products may be necessary for individuals with lactose intolerance, but it is not a specific behavior related to the DASH plan.

C. No longer includes grains in the daily diet:
The DASH eating plan includes whole grains as part of a balanced diet. Eliminating grains altogether is not consistent with the DASH plan, which encourages the consumption of whole grains.

D. Enjoys fat-free yogurt as an occasional snack food:
This is the correct answer. The DASH eating plan recommends the inclusion of low-fat or fat-free dairy products as part of a heart-healthy diet. Choosing fat-free yogurt as an occasional snack aligns with the principles of the DASH plan, which emphasizes low-fat dairy options.

A. Hyperactive bowel sounds. B. Anxiety and sighing. C. Dark yellow urine. D. Myalgia in wrists and hands.

Correct Answer is C

Explanation

A. Hyperactive bowel sounds.
Hyperactive bowel sounds are more suggestive of gastrointestinal issues, such as intestinal hypermotility or increased peristalsis. While diabetes can affect the gastrointestinal system, hyperactive bowel sounds are not a specific indicator of the symptoms described by the client.

B. Anxiety and sighing.
Anxiety and sighing are more indicative of emotional or psychological factors rather than dehydration. While stress can impact blood sugar levels in individuals with diabetes, anxiety and sighing are not direct signs of the dehydration that may be associated with the reported symptoms.

C. Dark yellow urine.
Dark yellow urine can be a sign of concentrated urine, suggesting dehydration. In diabetes, especially when blood sugar levels are elevated, increased urine production (polyuria) can lead to dehydration. Dark yellow urine may indicate that the urine is more concentrated due to a lack of fluid intake.

D. Myalgia in wrists and hands.
Myalgia in the wrists and hands is not a typical symptom of dehydration related to diabetes. It could be associated with various conditions, such as musculoskeletal issues or nerve-related problems. This symptom is less likely to be directly linked to the reported weakness and palpitations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

Correct Answer is D

Explanation

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

Correct Answer is C

Explanation

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

The nurse has conducted a cancer prevention community education program. In evaluating the participants understanding of the carcinogens, which statement indicates an accurate understanding?

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?