A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

Pain level of 1 on a scale of 0 to 10

Oxygen saturation of 92% on room air

Albumin level of 2.5 g/dL

Body mass index of 22

Answer and Explanation

The Correct Answer is C

Choice A reason: A pain level of 1 on a 0-10 scale indicates well-controlled pain, which does not directly impair wound healing. Adequate pain management supports mobility and recovery, reducing stress responses that could delay healing. This finding is not a risk factor for delayed wound healing in post-surgical clients.
Choice B reason: An oxygen saturation of 92% on room air is slightly low but not critically hypoxic. Wound healing requires adequate oxygenation, but levels above 90% are generally sufficient for tissue repair. This finding alone does not significantly indicate a risk for delayed wound healing compared to nutritional deficits.
Choice C reason: An albumin level of 2.5 g/dL (normal: 3.5-5.0 g/dL) indicates malnutrition, a major risk for delayed wound healing. Albumin is essential for tissue repair, collagen synthesis, and immune function. Low levels impair fibroblast activity and wound strength, increasing infection risk and slowing recovery in post-surgical clients.
Choice D reason: A body mass index of 22 is within the normal range (18.5-24.9) and does not indicate malnutrition or obesity, both of which can impair wound healing. Normal BMI supports adequate nutritional status for tissue repair, making this finding not a risk factor for delayed wound healing.

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Correct Answer is A

Explanation

Choice A reason: A subdural hematoma increases complication risk during electroconvulsive therapy (ECT) due to elevated intracranial pressure. ECT-induced seizures can worsen bleeding or cause herniation, posing significant neurological risks. This condition requires careful evaluation, making it the critical risk factor for complications.
Choice B reason: Hyperthyroidism may increase heart rate or metabolic demand but is not a primary risk for ECT complications. With proper management, it poses minimal risk compared to intracranial issues, so this is not the most concerning condition, making it incorrect.
Choice C reason: Renal calculi do not directly impact ECT safety, as they are unrelated to neurological or cardiovascular risks during seizures. This condition is manageable and not a significant complication risk, so it is incorrect for this scenario.
Choice D reason: Diabetes mellitus requires monitoring during ECT due to fasting or medication effects, but it is not a primary risk for complications. With proper glucose management, risks are minimal, so this is incorrect compared to a subdural hematoma’s impact.

A. Administer a dose of atomoxetine to reduce anxiety. B. Encourage the client to watch television. C. Sit with the client to provide a sense of security. D. Instruct the client to perform strenuous exercise.

Correct Answer is C

Explanation

Choice A reason: Administering atomoxetine, used for ADHD, is inappropriate for panic attacks, which require short-acting anxiolytics like benzodiazepines if medicated. This medication does not address acute anxiety and may worsen symptoms, making it incorrect and potentially harmful.
Choice B reason: Encouraging television watching may distract but does not address the acute distress of a panic attack. It lacks the calming, supportive presence needed to reduce anxiety, making it less effective and inappropriate compared to direct emotional support.
Choice C reason: Sitting with the client provides a calming presence, reducing fear and enhancing security during a panic attack. This therapeutic intervention supports emotional regulation and aligns with evidence-based anxiety management, making it the correct and most effective action.
Choice D reason: Instructing strenuous exercise during a panic attack can exacerbate symptoms like tachycardia and breathlessness, worsening anxiety. Calming techniques like deep breathing are preferred, so this action is counterproductive and potentially harmful, making it incorrect.

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A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is scheduled for electroconvulsive therapy. Which of the following conditions should the nurse identify as an increased risk for complications?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

A nurse on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” Which of the following responses by the nurse is appropriate? (Select all that apply)

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

A nurse is reviewing laboratory results for a client who is taking warfarin. Which of the following laboratory tests determines if the dose of medication is within the recommended target range?

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?