Nokea
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Bring additional sterile dressing supplies to the room.
- B. Auscultate the abdomen for bowel sound activity.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Evisceration is a surgical emergency requiring immediate operative repair to prevent complications.
You may also like to solve these questions
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory data which reveals a platelet count of 25,000/mm3 (25 x 109/L), which intervention should the nurse include in the plan of care?
- A. Ensure a large gauge IV catheter is used to obtain blood samples.
- B. Monitor urine and stool for occult blood regularly.
- C. Remove cold and frozen foods from dietary trays.
- D. Wrap bruised areas with elastic bandage dressings.
Correct Answer: B
Rationale: Monitoring for occult blood is critical with severe thrombocytopenia to detect internal bleeding early, preventing life-threatening complications.
The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
- A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
- B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
- C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground
- D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
Correct Answer: A,B,C,D
Rationale: Prioritization is based on the urgency and potential life-threatening nature of the conditions. The asthma attack is the highest priority due to potential airway compromise. Hypoglycemia is next due to the risk of neurological complications. Bleeding lacerations pose a risk of infection and blood loss, and the incontinent episode is primarily psychosocial, making it the lowest priority.
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. Hematocrit.
- B. Platelet count.
- C. White blood cell (WBC) count.
- D. Blood pH level.
Correct Answer: C
Rationale: WBC count indicates infection, as purulent drainage suggests bacterial colonization requiring prompt intervention.
Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. Which is the best explanation for the nurse to provide as to why a second medication has been added?
- A. Methotrexate has less harmful side effects than aspirin.
- B. Methotrexate helps to reduce the side effects of the aspirin therapy.
- C. Methotrexate enhances the effectiveness of the aspirin.
- D. Methotrexate slows the disease progression while aspirin controls the symptoms.
Correct Answer: D
Rationale: Methotrexate slows RA progression, while aspirin manages symptoms, addressing both disease and comfort.
Imaging Studies
Day 1, 1100
X-ray of right foot erosion of first metatarsal joint and preservation of joint space consistent with gout
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks
Select the 3 dietary choices that are not part of the recommended diet gout.
- A. Shrimp
- B. Sardines
- C. Quinoa
- D. Oranges
- E. Oatmeal
- F. Spinach
- G. Liver
Correct Answer: A,B,G
Rationale: Shrimp , sardines , and liver are high in purines, which increase uric acid levels and should be avoided in gout management.