Nokea
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
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The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for:
- A. Shellfish allergies
- B. Reactions to blood transfusions
- C. Gallbladder disease
- D. Egg allergies
Correct Answer: A
Rationale: Iodinated contrast used in cholangiograms can cause reactions in patients with shellfish or iodine allergies due to potential cross-reactivity.
The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?
- A. Encourage the client to express her feelings about the surgery.
- B. Insist that the client look at the surgical site.
- C. Perform the wound care without involving the client.
- D. Tell the client that she will feel better soon.
Correct Answer: A
Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns
The charge nurse is making assignments for the day shift. One of the nurses is 5 months pregnant. Which of the following clients is the most appropriate assignment for this expectant nurse?
- A. a client with shingles
- B. a client with measles
- C. a client with pneumonia
- D. a client with Clostridium difficile
Correct Answer: C
Rationale: Pneumonia is less likely to pose a risk to a pregnant nurse compared to shingles, measles (both vaccine-preventable and highly contagious), or C. difficile (requiring strict contact precautions).
A client with prostate cancer has been given the option of various treatments and asks the nurse for advice. Which of the following is the most appropriate response?
- A. Let's discuss the different options and how you feel about them.'
- B. I can't help you to make a treatment decision about your treatment.'
- C. You need to discuss this decision with your physician.'
- D. I would choose surgery if I were in your position.'
Correct Answer: A
Rationale: Discussing options and feelings (A) supports the client's decision-making without giving direct advice. Other responses (B, C, D) dismiss the client's request or overstep the nurse's role.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.