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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Redirecting to another nurse does not set a clear boundary with the client.
B. Ignoring (extinction) may escalate the behavior rather than appropriately managing it.
C. Setting clear and firm boundaries helps maintain structure and prevents manipulation, which is a key component of managing clients with antisocial behavior.
D. Introducing him to the newly admitted client and asking him to join the conversation may reinforce disruptive behavior.

A. Feelings of disorientation. B. Undiagnosed social anxiety symptoms (SAD). C. Family history of schizophrenia. D. History of suicide attempts.

Correct Answer is D

Explanation

A. Feelings of disorientation may be a symptom of heroin use, but addressing the client’s mental health, particularly suicidal tendencies, takes precedence.
B. Undiagnosed social anxiety symptoms may be important for long-term care, but the immediate concern is the risk of self-harm or overdose.
C. Family history of schizophrenia is relevant for mental health but does not take priority over assessing suicide risk in a client using heroin.
D. A history of suicide attempts is crucial for the nurse to consider because individuals using heroin may be at an increased risk of self-harm due to the psychological effects of substance use and potential for overdose. Immediate safety and suicide risk assessment are critical.

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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 psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is C

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

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Patient Data

Exhibits

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