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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.

Notify the surgeon

Place the client in low-Fowler's with knees raised

Start a peripheral IV (PIV)

Cover the wound with moistened sterile gauze

Hold pressure on the dressing

Encourage the client to drink fluids

Assist the client to cough and deep breathe

Answer and Explanation

Correct Answer : A,C,D

A. Notify the surgeon: The client has developed a wound dehiscence with evisceration of intestinal tissue, which is a serious surgical complication. Immediate communication with the surgeon is necessary to determine the next steps for repair and to avoid further complications, such as infection or organ injury.

B. Place the client in low-Fowler's with knees raised: While positioning is important for comfort and reducing pressure on the abdomen, placing the client in low-Fowler’s position is not the priority. The focus should be on protecting the eviscerated tissue and managing potential hypovolemia.

C. Start a peripheral IV (PIV): Starting a PIV is essential for administering fluids and medications, especially if the client requires resuscitation or further surgical intervention. The client's vital signs (decreased blood pressure, increased heart rate) suggest potential hypovolemia or shock, which may require IV fluids for stabilization.

D. Cover the wound with moistened sterile gauze: Evisceration requires immediate intervention to protect the exposed tissue. The nurse should cover the wound with sterile gauze that is moistened with normal saline to prevent the exposed intestines from drying out and to reduce the risk of infection. This is a critical step in managing the wound before further surgical intervention.

E. Hold pressure on the dressing: Applying pressure to the surgical dressing is not appropriate in this situation because it could cause more harm or further disrupt the wound. The wound should be covered with moistened sterile gauze to protect the eviscerated tissue, not pressured.

F. Encourage the client to drink fluids: Oral intake is not appropriate in the acute post-surgical phase when the client has experienced evisceration. The client may require surgical repair, and fluids should be administered intravenously to avoid the risk of aspiration or bowel perforation.

G. Assist the client to cough and deep breathe: While respiratory exercises are important for preventing atelectasis and pneumonia post-operatively, they are not an immediate priority in this situation where the client has evisceration. Stabilizing the wound and addressing potential shock takes precedence.

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Correct Answer is B

Explanation

A. Administering PRN oral analgesics is within the scope of a PN’s responsibilities and does not require an RN’s expertise.
B. The RN is responsible for supervising other nurses, including newly hired graduate nurses, and ensuring that assessments are performed competently.
C. Transporting a client is typically a task for a UAP, as long as it does not require complex nursing interventions.
D. Focused assessments of clients with wrist restraints can be performed by both an RN and a PN, but this is generally within the scope of the PN’s duties.

A. Reports of pain B. Nausea C. Difficulty breathing D. Hypotension E. Fetal decelerations F. Dizziness

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

Explanation

A. Reports of pain: While pain is a common complaint during labor, especially before the epidural takes effect or if the anesthesia is wearing off, this is not an immediate priority compared to other life-threatening complications like hypotension or fetal decelerations. It can be addressed once the more urgent issues are managed.

B. Nausea: Nausea may occur with epidural anesthesia, often due to hypotension, but it is not as urgent as respiratory distress, hypotension, or fetal decelerations. It can be managed after addressing the more critical symptoms.

C. Difficulty breathing: Difficulty breathing can be an indication of a high epidural block, which can affect the respiratory muscles. This is a serious sign that requires immediate intervention to assess and potentially correct the epidural anesthesia level.

D. Hypotension: Epidural anesthesia can cause hypotension due to sympathetic blockade. Low blood pressure can reduce uteroplacental perfusion and compromise fetal oxygenation, requiring prompt intervention with fluid boluses and/or vasopressors to support maternal and fetal circulation.

E. Fetal decelerations: Fetal heart rate decelerations, particularly late or variable decelerations, may indicate fetal distress, potentially caused by maternal hypotension, uteroplacental insufficiency, or cord compression. These should be promptly assessed and addressed to optimize fetal well-being.

F. Dizziness: Dizziness is often a result of epidural anesthesia-induced hypotension and is an early sign that should be assessed. However, it is not as immediately critical as difficulty breathing or fetal heart rate decelerations and should be addressed once the more urgent concerns are managed.

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Patient Data Exhibits Which should the nurse immediately do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is B

Explanation

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

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

Explanation

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Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to a healthcare provider for evaluation of thyroid functioning?

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.