Nokea
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
You may also like to solve these questions
Which of the following instructions should be included in the teaching for the client with arthritis?
- A. Avoid exercise because it fatigues the joints.
- B. Take prescribed anti-inflammatory medications with meals.
- C. Alternate heat and cold packs to the affected joints.
- D. Avoid weight bearing activity.
Correct Answer: B
Rationale: Taking anti-inflammatory medications with meals reduces gastrointestinal irritation, a key teaching point for arthritis management. Exercise and weight-bearing activities are encouraged, and heat/cold alternation is not universally recommended.
The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
- A. Impaired Skin Integrity.
- B. Knowledge Deficit: New Diabetes Diagnosis.
- C. Alteration in Nutrition: More than Body Requirements.
- D. Fluid Volume Deficit.
Correct Answer: B
Rationale: Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
The nurse is working on a plan to assist an abused client back into the work situation. Which will likely be most helpful in decreasing the trauma for the client?
- A. Support from significant others
- B. Support from a counselor
- C. Support from friends
- D. Support from coworkers
Correct Answer: A
Rationale: Support from significant others provides emotional stability, most effective in reducing trauma for an abused client re-entering work.
To minimize the side effects of a DPT immunization for a six-month-old.
The nurse should instruct the parents to
- A. give the child an alcohol bath for an elevated temperature.
- B. administer antipyretics for discomfort, irritability, and fever.
- C. place an ice bag on the child's leg for one hour.
- D. check the child's temperature every four hours for three days.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason