A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).

Place the client in a low Fowler's position with the knees bent.

Cover the client's wound with a sterile saline-soaked dressing.

Notify the surgeon about the finding.

Prepare the client for transfer to surgery.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.

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Correct Answer is A

Explanation

"I changed the floor plan of our home to accommodate my father's wheelchair.”.

Choice A rationale:

This statement indicates acceptance of the role change as a caregiver for the aging parents. Making changes to the home to accommodate the father's wheelchair demonstrates the client's willingness to adapt and provide a suitable environment for caregiving.

Choice B rationale:

Feeling stressed out and overwhelmed does not necessarily indicate acceptance of the role change. It may reflect the challenges and emotional burden that come with caregiving but does not necessarily signify acceptance.

Choice C rationale:

Expressing frustration with caregiving does not necessarily indicate acceptance of the role change. It is normal to feel frustrated at times, especially when dealing with chronic illnesses, but acceptance involves embracing the responsibilities that come with the role.

Choice D rationale:

While the statement shows a willingness to learn and adapt to caregiving, it does not explicitly indicate acceptance of the role change. Acceptance involves acknowledging and embracing the new responsibilities and challenges fully.

A. Take this medication on an empty stomach. B. Avoid drinking grapefruit juice while taking this medication. C. Change positions slowly while taking this medication. D. This medication can cause insomnia. E. It is possible to experience involuntary movements while taking this medication.

Correct Answer is ["B","D"]

Explanation

Choice A rationale:
Lurasidone does not necessarily need to be taken on an empty stomach. It can be taken with or without food.
Choice B rationale:

Avoiding grapefruit juice is essential with lurasidone as it can interfere with the drug's metabolism and increase the risk of side effects.
Choice C rationale:
Changing positions slowly is relevant for medications that can cause orthostatic hypotension, but lurasidone is not typically associated with this side effect.
Choice D rationale:
Lurasidone can cause insomnia in some individuals, so it is important for the client to be aware of this potential side effect. It is best taken in the evening to minimize this effect.
Choice E rationale:
While involuntary movements (extrapyramidal symptoms) can occur with some antipsychotic medications, lurasidone has a lower risk of causing these side effects compared to older antipsychotics. It is not a major concern with lurasidone treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

Correct Answer is A

Explanation

A nurse is teaching a client who has schizophrenia a new prescription for lurasidone. Which of the following information should the nurse include in the teaching?(Select all that apply.).

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client who has multiple sclerosis. Which of the following manifestations should the nurse expect?

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

A nurse is reviewing the laboratory results for four clients. Which of the following results is the priority for the nurse to report to the provider?

A nurse in a PACU is caring for a client who is postoperative. Which of the following findings should the nurse report to the provider?

A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect?

A nurse is planning care for a client who has long-term liver cirrhosis and a new diagnosis of abdominal ascites. Which of the following interventions should the nurse include in the plan of care to prevent complications?