An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

Evisceration.

Hemorrhage.

Infection.

Dehiscence.

Answer and Explanation

The Correct Answer is A

A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.

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Correct Answer is B

Explanation

A. Wearing gloves during breakfast service is not always required, and the focus should be on ensuring proper hand hygiene rather than glove use.
B. The hand rub should be completed in 20-30 seconds, and the UAP’s 2-minute hand rub is excessive. Proper hand hygiene techniques should be reinforced.
C. The UAP does not need to remain in the client's room during hand hygiene; the primary issue is the duration of the hand rub.
D. Inspecting the hands for cleanliness is not necessary if the hand hygiene practice is incorrect; instead, correcting the technique is more important.

A. Course breath sounds B. Irritability C. Seizure activity D. Decreased level of consciousness E. Bradycardia

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.

Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.

Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.

Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).

Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.

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An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) using an alcohol-based cleanser after delivering a client's breakfast tray to the room. The UAP rubs both hands thoroughly for 2 minutes while standing at the door to the client's room. Which action should the PN take?

Correct Answer is B

Explanation

Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

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