A nurse is caring for a client who had abdominal surgery 3 days ago.
Exhibits
Select words from the choices below to fill in each blank in the following
sentence.
The client is at risk for developing Target 1 dropdown Target 2 dropdown and ___Target 3 dropdown .
The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"B"}
Wound infection: The presence of purulent drainage and redness at the incision site indicates a risk for infection, especially given the client's surgical history and risk factors (obesity, diabetes).
Dehiscence: The noted separation of the top edges of the incision and stretched upper staples increases the risk of dehiscence, which can occur due to tension, infection, or inadequate healing.
Pneumonia: The client is febrile, has crackles upon auscultation, and may be at risk for pneumonia due to decreased mobility and shallow breathing, which can occur post-surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ripe bananas can help alleviate diarrhea due to their fiber content and are often recommended to regulate bowel movements.
B. Caffeinated beverages, such as coffee and tea, are known to increase intestinal motility and can lead to diarrhea.
C. White rice is a low-fiber, easily digestible food that typically helps manage diarrhea.
D. Low-fiber cereals are not likely to cause diarrhea, as fiber tends to bulk stool rather than loosen it.
Correct Answer is ["A","B","C"]
Explanation
The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.
A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.
Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.
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