A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Visualize the abdominal incision.

Notify the healthcare provider.

Obtain sterile towels soaked in saline.

Assure the client that such feelings occur with wound infections.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

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Correct Answer is D

Explanation

Choice A reason: Hematuria is expected after lithotripsy and should be monitored, but it is not the most critical instruction.

Choice B reason: Using an incentive spirometer is important for respiratory care but not specific to lithotripsy.

Choice C reason: Restricting physical activities is not necessary unless advised by the healthcare provider.

Choice D reason:

The correct answer is d) because monitoring the urinary stream for a decrease in output is crucial to detect any complications such as obstruction or infection after lithotripsy.

A. Determine the ability to chew and swallow. B. Assess patterns of speech. C. Note the frequency of drooling. D. Observe the appearance of oral mucosa.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because a mask-like face in Parkinson's disease can affect the ability to chew and swallow, increasing the risk of aspiration and nutritional deficiencies.

Choice B reason: Assessing speech patterns is important but secondary to ensuring the client can chew and swallow safely.

Choice C reason: Noting the frequency of drooling can indicate difficulties with swallowing, but determining the ability to chew and swallow is more critical.

Choice D reason: Observing the appearance of the oral mucosa is important for overall oral health but does not address the immediate risk of aspiration and nutritional concerns.

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A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

Correct Answer is D

Explanation

The nurse observes that a client with Parkinson's disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?

Correct Answer is A

Explanation

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