A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Ask someone to quickly get an abdominal binder.

Assist the patient in a supine position.

Seat the patient in a nearby chair.

Instruct the patient to pant to reduce abdominal tension.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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Correct Answer is B

Explanation

Choice A rationale:

Abdominal pads are not designed to minimize pain during dressing changes.

Choice B rationale:

Hydrogel dressings are known to minimize pain during dressing changes.

Choice C rationale:

Wet-to-dry dressings can cause discomfort during dressing changes.

Choice D rationale:

Dry gauze can stick to the wound bed and cause pain during dressing changes.

A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Double bag the dressing, label it "biohazard," and send it for decontamination. C. Place the dressing in a biohazardous waste container. D. Discard the dressing in the bedside trash receptacle.

Correct Answer is C

Explanation

Choice A rationale:

Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice B rationale:

Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.

Choice C rationale:

Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.

Choice D rationale:

Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

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A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is: