A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Prepare to obtain a wound culture.

Restrict fluid intake.

Administer an analgesic

Prepare to administer an antibiotic

Initiate supplemental oxygen.

Answer and Explanation

Correct Answer : A,C,D

A. Prepare to obtain a wound culture: A culture is necessary if infection is suspected.
B. Restrict fluid intake: Contraindicated as hydration is important to support healing and kidney function.
C. Administer an analgesic: Pain management is crucial postoperatively.
D. Prepare to administer an antibiotic: Antibiotics are indicated for infection prophylaxis or treatment.
E. Initiate supplemental oxygen: Not needed unless signs of respiratory distress or hypoxia are present.

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Correct Answer is C

Explanation

A. "Perform breast self-examinations during the middle of your cycle.": The best time for premenopausal clients to perform a breast self-exam is 5-7 days after the menstrual period ends, when hormonal fluctuations are minimal, and the breasts are less tender.
B. "Perform breast self-examinations while lying on your side.": The recommended position for self-examination is lying flat with the arm on the side being examined raised above the head, as this spreads the breast tissue more evenly.
C. "Use small, circular motions, working vertically up and down across the breast.": The vertical strip method, using small circular motions, is the recommended technique for thorough breast self-examination. It ensures that all breast tissue is palpated, including the axillary area.
D. "Use the palm of your hand to detect the presence of any large masses under the skin.": The pads of the fingers, not the palm, are used to palpate the breast for lumps or abnormalities.

A. Current medication prescriptions B. Primary health problem C. Number of family members who have visited D. Admission vital signs from 1 week ago E. Scheduled times for dressing changes

Correct Answer is ["A","B","E"]

Explanation

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

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A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is premenopausal. Which of the following statements by the nurse is appropriate regarding breast self-examinations?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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A nurse is assisting in the care of the client who is postoperative following a fasciotomy.

Exhibits

Which of the following actions should the nurse take? Select all that apply.