A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Place the head of the client's bed flat with the client's legs extended.

Apply butterfly strips to approximate the wound edges.

Apply pressure directly to the wound for 15 min.

Place a sterile, saline-soaked dressing on the wound.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

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Correct Answer is ["A","B","D","G"]

Explanation

Rationale for Correct Answers:

Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

A. 1 cup sliced peaches B. 1 cup sliced banana C. 1 cup sliced kiwifruit D. 1 cup cubed cantaloupe

Correct Answer is C

Explanation

A. 1 cup sliced peaches: Peaches contain some vitamin C but in lower amounts compared with other fruits. They are not the highest source for meeting daily vitamin C needs in toddlers.

B. 1 cup sliced banana: Bananas provide minimal vitamin C and are better known for their potassium content. They are not an effective choice for significantly increasing vitamin C intake.

C. 1 cup sliced kiwifruit: Kiwifruit is exceptionally high in vitamin C, providing more than the daily requirement for a toddler in a single cup. It is an excellent choice for boosting vitamin C intake.

D. 1 cup cubed cantaloupe: Cantaloupe contains vitamin C but in moderate amounts. While beneficial, it is less concentrated than kiwifruit for meeting vitamin C needs.

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A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","D","G"]

Explanation

A nurse is teaching a parent about increasing vitamin C in her toddler's diet. Which of the following food choices should the nurse recommend as the best source of vitamin C?

Correct Answer is C

Explanation

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