Which client should a nurse evaluate first on a surgical unit?
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”.
A two-day postoperative client who has bile-colored fluid draining from his nasogastric tube and says, “I feel like I might vomit.”.
A three-day postoperative client who has an ileostomy and reports the need to have a bowel movement.
A three-day postoperative client who is receiving intravenous antibiotics for a wound infection.
The Correct Answer is A
A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.
The nurse should evaluate this client first and notify the surgeon.
Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.
The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.
Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.
The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.
Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.
The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Decreased sensory acuity. This is a physiological change that occurs in elderly people due to the reduced function of the sensory organs, such as the eyes, ears, nose, tongue, and skin. Elderly people may experience impaired vision, hearing loss, reduced smell and taste, and decreased touch sensitivity.
Choice A is wrong because diminished attention span is not a normal physiological change in elderly people. It may be a sign of cognitive impairment or dementia.
Choice C is wrong because the increased need for rest is not a normal physiological change in elderly people. It may be a sign of fatigue, depression, or medical conditions.
Choice D is wrong because enhanced intestinal motility is not a normal physiological change in elderly people. It may be a sign of gastrointestinal disorders or infections.
Correct Answer is B
Explanation
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
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