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:

An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.

Choice B rationale:

An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.

Choice C rationale:

A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.

Choice D rationale:

A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.

A. Decreased serum calcium. B. Decreased circulation. C. Increased collagen. D. Increased muscle mass.

Correct Answer is B

Explanation

Choice A rationale:

Decreased serum calcium does not directly contribute to pressure injury development.

Choice B rationale:

Decreased circulation can lead to tissue ischemia and necrosis, increasing the risk of pressure injury.

Choice C rationale:

Increased collagen is beneficial for wound healing and does not increase the risk of pressure injury.

Choice D rationale:

Increased muscle mass can actually provide more padding over bony prominences, reducing the risk of pressure injury.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

Correct Answer is C

Explanation

A nurse is collecting data on a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

Correct Answer is B

Explanation

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