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
Explanation
Choice A rationale:
An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.
Choice B rationale:
A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.
Choice D rationale:
A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.
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.
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