Nokea
On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action?
- A. Flush the wound with sterile water.
- B. Apply an abdominal binder.
- C. Cover the wound with a sterile dressing moistened with normal saline.
- D. Apply strips of tape.
Correct Answer: C
Rationale: Covering the wound with a sterile dressing moistened with normal saline protects the open wound from infection and keeps it moist until further medical evaluation. Flushing, applying a binder, or using tape are inappropriate without addressing the dehiscence first. CN: Physiological adaptation; CL: Synthesize
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The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
- A. Cardiac arrhythmias.
- B. Liver failure.
- C. Renal failure.
- D. Hemorrhage.
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client's vital signs
- B. Administer a bolus of lactated Ringer's solution
- C. Assess the client's neurologic status
- D. Contact the physician
Correct Answer: A
Rationale: Sharp midchest pain in a client with a thoracic aneurysm suggests possible dissection or rupture, a life-threatening emergency. Assessing vital signs (e.g., hypotension, tachycardia) first provides critical data to guide action. Fluid bolus, neurologic assessment, or contacting the physician follow based on findings.
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will:
- A. Exhibit no further episodes of short-term memory loss.
- B. Be able to return to his construction job in 3 weeks.
- C. Actively participate in the rehabilitation process as appropriate.
- D. Re campaign to the end display pre-injury personality traits.
Correct Answer: C
Rationale: Active participation in rehabilitation is a realistic and appropriate outcome, promoting recovery tailored to the client's abilities. Eliminating memory loss, returning to a physically demanding job soon, or fully restoring pre-injury personality are unrealistic due to the severity of the injury.