Nokea
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
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A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
- A. Empty the pouch when it is 1/3 to 1/2 full.
- B. Use a standard enema set to irrigate the colostomy.
- C. Cleanse the skin surrounding the stoma with moisturizing soap.
- D. Cut the opening in the skin barrier 1/4 inch larger than the stoma.
Correct Answer: A
Rationale: Emptying the pouch when 1/3 to 1/2 full prevents leakage and maintains skin integrity, a key aspect of ostomy care.
Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
A nurse is assisting with the care of the client Complete the following sentence by using the list of options. The nurse should first plan to.... followed by.....
- A. Determine if the nasogastric tube is in the correct position
- B. Provide oral care to the client
- C. Increase nasogastric tube suction
- D. Request a prescription for an antiemetic
- E. Document the client's pain level
- F. Monitor the client's electrolyte levels
Correct Answer: A,D
Rationale: The nurse should first ensure the nasogastric tube is correctly placed to address vomiting and obstruction, followed by requesting an antiemetic to manage nausea.
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Each finding might support more than 1 disease process.
- A. Dyspnea
- B. Increased pain at incision site
- C. Tingling sensation to right foot
- D. Swelling at incision site
Correct Answer: A (fat embolism syndrome), B (acute compartment syndrome, infection), C (acute compartment syndrome), D (acute compartment syndrome, infection)
Rationale: Dyspnea is typical of fat embolism; increased pain and swelling suggest compartment syndrome or infection; tingling indicates compartment syndrome.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Changed mental status
- B. Temperature 37.3°C (99.1°F)
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: A
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.