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 C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A. Use small ice cubes. B. Fill the pack and refreeze it. C. Use a light cover on the pack. D. Cover the pack with plastic wrap.

Correct Answer is C

Explanation

Choice A rationale:

Using small ice cubes is not necessary when applying an ice pack. The size of the ice does not affect the therapeutic effect of the cold therapy.

Choice B rationale:

It is not necessary to fill the pack and refreeze it. The ice pack should be used as is and can be refrozen after use if needed.

Choice C rationale:

Using a light cover on the pack is necessary to prevent direct contact of the ice with the skin, which can cause cold injury or frostbite.

Choice D rationale:

Covering the pack with plastic wrap is not necessary. The ice pack usually comes in a waterproof bag that prevents water leakage.

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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

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

When applying an ice pack, it is necessary to:

Correct Answer is C

Explanation

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

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?

Superficial wounds heal faster when kept:

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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:

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to:

Enter instructional text.The nurse clarifies that the second stage of wound healing is:

The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)