The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Cover the bowel with wet sterile gauze

Assist the client into a low-Fowler's position with knees flexed

Assist the client into a side-lying position with knees flexed

Retrieve the crash cart from the nursing station

Call for assistance

Measure the client's inspiratory volume via incentive spirometer

Answer and Explanation

Correct Answer : A,B,E

A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.

B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.

C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.

D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.

E: Calling for assistance is essential to notify the surgical or medical team promptly.

F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.

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Correct Answer is D

Explanation

A. Hyperthermia is not commonly associated with diazepam.

B. Hypertension is not a common concern with diazepam use.

C. Tachycardia is not a significant side effect of diazepam.

D. Respiratory depression is the most serious and potentially life-threatening side effect of diazepam, requiring close monitoring.

A. "Tell me about your fear of receiving a blood transfusion." B. "Your request to not receive a transfusion will be honored. Your consent is needed to administer blood or blood products." C. "Are you sure? Please consider the risk you are taking if you refuse a blood transfusion." D. "You don't need to worry about getting a blood transfusion. Blood loss is minimal with this procedure."

Correct Answer is B

Explanation

A. Assuming the client’s decision is based on fear may feel dismissive of their beliefs.

B. Acknowledging and respecting the client’s decision while confirming their right to consent honors their autonomy and builds trust.

C. Questioning the client’s decision undermines their beliefs and autonomy.

D. Reassuring the client about blood loss dismisses their valid concerns about transfusion refusal.

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The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving diazepam prior to a procedure. Which side effect should the nurse be most concerned about?

Correct Answer is D

Explanation

During a pre-surgical admission assessment, a client states. "I've told my surgeon that I am Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate?

Correct Answer is B

Explanation

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