Exhibits

Highlight findings that indicate the client is stable and ready to be discharged.

The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. The client is currently resting in bed. The incision dressing is dry and intact, and no bleeding is noted. The client tolerated clear liquids post recovery and has advanced to a soft diet. The client ambulated around the unit this morning and tolerated activity well. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO.

incision dressing is dry and intact, and no bleeding is noted

The client tolerated clear liquids post recovery and has advanced to a soft diet

The client ambulated around the unit this morning and tolerated activity well

Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus

Pain is tolerated with analgesia PO

Answer and Explanation

The Correct Answer is ["A","B","C","D","E"]

The incision dressing is dry and intact, with no bleeding noted: This indicates that the surgical site is healing well without any signs of infection or complications. A dry and intact dressing suggests that there is no active bleeding or wound drainage, which is a positive sign of wound healing.

The client has tolerated clear liquids post-recovery and has advanced to a soft diet: Progression from clear liquids to a soft diet indicates that the client's gastrointestinal function is returning to normal. This progression suggests that there are no immediate concerns regarding postoperative nausea, vomiting, or bowel obstruction.

The client has ambulated around the unit and tolerated activity well: Ambulation and tolerance of activity demonstrate the client's physical mobility and overall strength. Being able to move around the unit without difficulty suggests that the client is recovering well from the surgical procedure and is regaining strength and function.

Bowel sounds are present in all 4 quadrants, and the client has passed flatus: The presence of bowel sounds in all four quadrants indicates normal gastrointestinal motility and function. Passing flatus is another positive sign of gastrointestinal recovery, suggesting that the client's bowels are active and functioning properly post-surgery.

Pain is tolerated with analgesia orally: The client's ability to tolerate pain with oral analgesia indicates effective pain management and suggests that the surgical incision site is not causing significant discomfort or distress. Effective pain control is essential for postoperative comfort and can facilitate the client's recovery process.

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Correct Answer is B

Explanation

A. This is an open-ended question, not closed-ended.

B. A closed-ended question like "Does your pain occur when walking short distances?" is specific and allows the nurse to understand the triggers and pattern of the pain, which is important for assessing unstable angina.
C. "When did you first notice the pain in your chest?" is also a relevant question but less specific to understanding the current pattern and triggers of the pain.
D. "How do you feel when the pain becomes noticeable?" is open-ended and less specific in identifying triggers and patterns of the pain.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Encouraging the client to sit up and ambulate helps prevent complications such as atelectasis and deep vein thrombosis by promoting lung expansion and blood circulation.
B. While monitoring for bleeding is important, in most stable postoperative cases, continuous monitoring isn't necessary. Once daily checks are often sufficient.
C. Regular use of the incentive spirometer helps prevent respiratory complications such as pneumonia by promoting deep breathing and lung expansion.
D. Adequate hydration is essential for wound healing, preventing urinary retention, and maintaining overall physiological function. Encourage the client to drink fluids within their prescribed limits.
E. Monitoring for sedation after administering pain medications is crucial to ensure the client's safety and prevent respiratory depression. Assess the client's level of consciousness, respiratory rate, and oxygen saturation regularly.
F. Neurological assessments are usually not required this frequently unless there are specific concerns.
G. Administering pain medication after activity helps manage postoperative pain effectively, enabling the client to participate in necessary activities such as ambulation and respiratory exercises. It's important to ensure that pain is adequately controlled to facilitate recovery and promote comfort.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

Correct Answer is B

Explanation

Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

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