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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
D.
Choice A rationale:
A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.
Choice B rationale:
Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.
Choice C rationale:
Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.
Choice D rationale:
Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.
Choice E rationale:
A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.
Correct Answer is D
Explanation
Choice A rationale:
Sharp debridement involves the use of a sharp instrument or heat to remove dead tissue, which is not achieved with a hydrocolloid dressing.
Choice B rationale:
Chemical debridement involves the use of chemicals to remove dead tissue, which is not the function of a hydrocolloid dressing.
Choice C rationale:
Enzymatic debridement involves the use of enzymes to soften and remove dead tissue, which is not the function of a hydrocolloid dressing.
Choice D rationale:
Autolytic debridement uses the body’s own enzymes and moisture to soften and remove dead tissue. A hydrocolloid dressing helps maintain a moist wound environment, promoting autolytic debridement.
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