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: Providing additional oral fluids is not appropriate for SIADH and can worsen fluid retention.

Choice B reason: Measuring glucose levels is important for diabetes management but not directly related to SIADH.

Choice C reason: Using hard candy may help relieve thirst but does not address the underlying issue of fluid retention in SIADH.

Choice D reason:

The correct answer is d) because withholding diuretics and contacting the healthcare provider is necessary to manage the fluid balance in clients with SIADH.

A. Deep partial-thickness. B. Full-thickness. C. Superficial partial-thickness. D. Deep full-thickness.

Correct Answer is B

Explanation

Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.

Choice B reason:

The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.

Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.

Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.

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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 chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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