Exhibits

The client has recovered from surgery and is ready to be discharged.

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.

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

Answer and Explanation

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

Dressing is dry and intact with no signs of bleeding or infection: A clean, dry, intact incision with no drainage, erythema, or swelling indicates proper wound healing and a low risk of post-operative infection. Post-appendectomy clients must be assessed for potential wound complications like dehiscence (wound reopening) or infection (redness, purulent drainage, warmth). Since no abnormalities are reported, the client’s surgical site is healing well, supporting discharge readiness.

Successfully advanced from clear liquids to a soft diet without issues: After surgery, clients are started on a clear liquid diet to assess tolerance. If no nausea, vomiting, or bloating occurs, they progress to a soft diet before discharge. Tolerance to oral intake ensures the gastrointestinal (GI) tract is functioning and that the client can maintain adequate nutrition and hydration at home.

Client has ambulated around the unit and tolerated activity well: Early ambulation after surgery is crucial in preventing complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative ileus (temporary bowel paralysis). Tolerating ambulation means the client can move independently, reducing the risk of complications related to prolonged bed rest, such as muscle deconditioning and respiratory complications.

Bowel sounds are present in all four quadrants, and the client has passed flatus: The presence of bowel sounds in all quadrants and the passage of flatus (gas) are key indicators that the intestines are resuming normal function after surgery.

Postoperative ileus, a common complication after abdominal surgery, can delay discharge if present. The return of bowel function suggests that the GI system is recovering appropriately, allowing the client to eat and digest food normally.

Pain is well-controlled with oral analgesia: Pain control is an essential criterion for discharge. The client must be able to manage discomfort at home with prescribed oral medications. The ability to tolerate oral analgesics (instead of IV pain management) means the client is independent of hospital-based interventions, making home recovery feasible.

Nursing Test Bank

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Correct Answer is C

Explanation

A. While measuring body temperature is important for infection monitoring, it is not the primary concern after prasugrel administration.
B. Pedal edema is not a common side effect of prasugrel and does not directly relate to its adverse effects.
C. Prasugrel is an antiplatelet medication that increases the risk of bleeding. Monitoring for signs of bleeding, such as blood in the urine (hematuria), is important to assess for adverse effects.
D. Assessing skin turgor is important for hydration status but does not address bleeding risks associated with prasugrel.

A. Encourage the use of assistive feeding devices. B. Demonstrate use of a tucked-chin position while eating. C. Assist the client to lie down and turn to the side. D. Recommend the use of supplemental liquid feedings.

Correct Answer is B

Explanation

A: Assistive feeding devices may help, but they do not directly address the risk of aspiration. Improving swallowing mechanics is more immediately beneficial.

B: The tucked-chin position helps protect the airway by improving swallowing coordination and reducing the risk of aspiration during meals. It is a simple technique that can significantly help clients with swallowing difficulties.

C: Lying down can increase the risk of aspiration by allowing food to enter the airway more easily.

D: Supplemental liquid feedings may be necessary for some ALS patients, but addressing the client’s swallowing technique during meals should take priority to prevent aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

Correct Answer is C

Explanation

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Correct Answer is B

Explanation

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

A client with Parkinson's disease (PD) is admitted to the medical surgical unit and the nurse assesses the client's mobility needs. Which finding(s) indicate the need to plan interventions related to the client's mobility? Select all that apply.

Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Drag from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.