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 A

Explanation

Choice A reason:

The correct answer is a) because observing the color of the extremity provides additional information about circulation and potential complications such as compartment syndrome.

Choice B reason: Notifying the healthcare provider is necessary if there are abnormal findings.

Choice C reason: Discontinuing elevation is not necessary unless there are signs of compromised circulation.

Choice D reason: Documenting the assessment as normal comes after completing a thorough assessment.

A. Chicken, rice, and wheat products. B. Lean beef, salads, and baked potatoes. C. Oatmeal, raisins, and fruit with skin. D. Potatoes, low-fat breads, and applesauce.

Correct Answer is C

Explanation

Choice A reason: While chicken and rice are healthy, they do not specifically address the benefits of fiber in cancer prevention.

Choice B reason: Lean beef is not recommended for reducing the risk of colon cancer, although salads and baked potatoes are healthy choices.

Choice C reason:

The correct answer is c) because oatmeal, raisins, and fruit with skin are high in fiber, which can help reduce the risk of colon and rectal cancers.

Choice D reason: Potatoes and low-fat breads are healthy but do not provide as much fiber as oatmeal, raisins, and fruit with skin.

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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?

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