A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
Assess fluid intake every 24 hr.
Ambulate three times a day.
Assist with deep breathing and coughing.
Monitor the incision site for findings of infection.
The Correct Answer is C
A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A mastectomy is a surgical procedure that involves the removal of all or part of the breast, usually to treat breast cancer. A mastectomy can have a significant impact on a woman's physical, emotional, and psychological well-being, as it may affect her body image, self-esteem, sexuality, and identity.
- A mastectomy incision is the wound that results from the surgery, which may vary in size, shape, and location depending on the type and extent of the mastectomy. The incision may be closed with stitches, staples, or glue, and covered with a dressing or bandage.
- The first dressing change is usually done within 24 to 48 hours after the surgery, and it involves removing the old dressing, inspecting the incision for any signs of infection or complications, cleaning the wound, applying a new dressing, and educating the client about wound care .
- When the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it, this may indicate that the client is experiencing denial, fear, anger, grief, or depression due to the loss of her breast. These are normal and common reactions that may occur at different stages of the recovery process .
- The best response by the PN to the client's silence is to acknowledge and respect the client's feelings, provide support and reassurance, and offer assistance when needed. This will help to establish trust and rapport with the client, as well as promote her coping and adjustment .
- Therefore, option A is the best answer, as it shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.
- Options B, C, and D are incorrect answers, as they do not show empathy or respect for the client's
feelings, and they may cause more harm than good.
Option B is incorrect because asking another nurse to be present may not address the client's reluctance or
anxiety about looking at her incision.
Option C is incorrect because telling the client that part of recovery is accepting her new body image may
sound insensitive or judgmental, and it may not reflect the client's readiness or willingness to do so.
Option D is incorrect because telling the client that she will feel beter when she sees that the incision is not as bad as she may think may minimize or invalidate the client's feelings, and it may not be true or helpful.
Correct Answer is B
Explanation
A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.
B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.
C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.
D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.
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