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:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

A. Karaya paste. B. Paper tape. C. Elastic adhesive tape. D. Montgomery straps.

Correct Answer is D

Explanation

Choice A rationale:

Karaya paste is used for ostomy care, not for dressing changes.

Choice B rationale:

Paper tape might not provide the necessary adhesion for frequent dressing changes.

Choice C rationale:

Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.

Choice D rationale:

Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.

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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

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

Correct Answer is C

Explanation

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal.The nurse would change the dressing procedure in order to use:

Correct Answer is D

Explanation

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 performing a right eye irrigation will position the patient:

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

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

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?

Chronic wounds that are not healing well may benefit from (Select all that apply.)