Which action is essential when assessing for drainage in a client with a large abdominal wound?

Feel the top of the client’s legs.

Examine area underneath the client.

Ask the client to cough forcefully.

Have the client sit up and lean forward.

Answer and Explanation

The Correct Answer is B

This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.

Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.

Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.

Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.

Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.

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Correct Answer is A

Explanation

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).

A. A slice of fruit pie. B. One cup of gelatin. C. A bran muffin. D. One plain doughnut.

Correct Answer is B

Explanation

This is because gelatin is a low-fat dessert that contains only 0.1 grams of fat per cup.

It is also low in calories and can be flavored with fruit juice or fresh fruits for added nutrition.

Choice A is wrong because a slice of fruit pie contains about 14 grams of fat per slice, which is high for a low-fat diet.

Fruit pies also have added sugar and refined flour that can increase the calorie intake.

Choice C is wrong because a bran muffin contains about 9 grams of fat per muffin, which is also high for a low-fat diet.

Bran muffins may have some fiber benefits, but they also have added sugar and oil that can make them less healthy.

Choice D is wrong because one plain doughnut contains about 11 grams of fat per doughnut, which is also high for a low-fat diet.

Doughnuts are deep-fried and have a lot of sugar and refined flour that can contribute to weight gain and health problems.

Some other examples of low-fat dessert choices are sorbet, fruit salad, yogurt, pudding, and angel food cake.

These desserts are lower in fat and calories than pies, muffins, and doughnuts, and can satisfy a sweet tooth without compromising the dietary instructions.

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Which action is essential when assessing for drainage in a client with a large abdominal wound?

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Naxlex Comprehensive Predictor Exams

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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