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A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care?
- A. Remove the dressing and leave the incision open to air.
- B. Remove the drain if wound drainage is minimal.
- C. Gently irrigate the drain to remove exudate.
- D. Clean the area around the drain moving away from the drain.
Correct Answer: D
Rationale: When providing wound care, the nurse should clean the area around the drain moving away from the drain to prevent introducing pathogens into the wound. Leaving the incision open, removing the drain, or irrigating are not appropriate without specific orders. CN: Physiological adaptation; CL: Synthesize
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A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
As a result of a gastric resection, the client is at risk for development of dumping syndrome. The nurse should prepare a plan of care for this client based on knowledge that this problem stems primarily from which of the following gastrointestinal changes?
- A. Excess secretion of digestive enzymes in the intestines.
- B. Rapid emptying of stomach contents into the small intestine.
- C. Excess glycogen production by the liver.
- D. Loss of gastric enzymes.
Correct Answer: B
Rationale: Dumping syndrome occurs due to rapid emptying of stomach contents into the small intestine, causing osmotic and vasomotor symptoms. The other options are not primary causes.
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased: decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following first?
- A. Encourage the client to drink at least 1,000 mL per day.
- B. Provide parenteral rehydration therapy ordered by the physician.
- C. Turn and reposition every 2 hours.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: The client's symptoms indicate dehydration, requiring immediate parenteral rehydration therapy as ordered to restore fluid balance. Oral fluids, repositioning, or monitoring are less urgent or inappropriate as the first action. CN: Physiological adaptation; CL: Synthesize