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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Rationale:

Polyhydramnios: Excess amniotic fluid can overdistend the uterus, reducing its ability to contract effectively after delivery, which increases the risk of uterine atony and postpartum hemorrhage.

Prolonged rupture of membranes: A long duration of ruptured membranes increases the risk of bacteria ascending into the uterus, which can lead to endometritis and systemic infection postpartum.
Prenatal anemia: Low hemoglobin levels reduce oxygen delivery to tissues and impair the immune response, increasing susceptibility to infections such as endometritis or wound infection after cesarean birth.
High parity: Multiple pregnancies can cause stretching and weakening of the uterine muscle, which may result in inadequate contraction postpartum, predisposing the client to uterine atony.

A. Provide the client with high-calorie fluids every hour. B. Encourage the client to avoid napping during the day. C. Minimize environmental stimuli for the client. D. Weigh the client each day.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.

Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.

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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

A nurse on a postpartum unit is caring for a client. Exhibits For each finding, click to specify if the finding increases the client's risk for uterine atony or infection.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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