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: Warm, soft, moist, salmon-colored skin is not typical of Cushing's syndrome.

Choice B reason: Visible swelling of the neck, with no pain, is not specific to Cushing's syndrome.

Choice C reason: A husky voice and trouble with hoarseness are not typical of Cushing's syndrome.

Choice D reason:

The correct answer is d) because central-type obesity with thin extremities is a characteristic feature of Cushing's syndrome.

A. The nurse will demonstrate the procedure for accurate eye care. B. The client's blood pressure readings will be less than 160/90 mm Hg. C. The client's hemoglobin A1C will be less than 7% in 3 months. D. The nurse will encourage the client to walk thirty minutes every day.

Correct Answer is C

Explanation

Choice A reason: Demonstrating accurate eye care is important but is not a measurable outcome for managing diabetes.

Choice B reason: Managing blood pressure is important but not the primary goal in the context of newly diagnosed diabetes.

Choice C reason:

The correct answer is c) because achieving a hemoglobin A1C of less than 7% in 3 months is a measurable and relevant outcome for managing type 2 diabetes. It indicates good glycemic control and helps prevent complications.

Choice D reason: Encouraging physical activity is beneficial but is not a specific measurable outcome for diabetes management.

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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

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

Correct Answer is C

Explanation

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