PN~CD~Questions~1601-1700 -
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Comprehensive Review CD Questions
1601-1700{<AQ> question: 1624, 1631 (Note to developer: the student will need to use a dragand drop feature to answer Question 1631 and list the nursing actions in order of priority. The correct order of action is provided in the answer.); formula: 1624}
1601. A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the initial nursingaction is to assess the:1. Abdominal dressing2. Urinary output in the Foley bag3. Intravenous (IV) solution for accurate flow rate4. Vital signsAnswer: 4Rationale:
The initial nursing action is to assess the client’s vital signs. The vital signswill provide information regarding airway, breathing, and the circulatory status of theclient. Additionally, this data provides a baseline for further assessments. The abdominaldressing, IV, and urine output are also components of the assessment, and theseassessments would follow the assessment of the vital signs.Test-Taking Strategy:
Use the principles of prioritization when answering this question.Use the ABCs—airway, breathing, and circulation. Vital signs provide data regardingairway, breathing, and circulation. Options 1, 2, and 3 are all nursing actions that should be performed after vital signs. Review care to the postoperative client if you haddifficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Delegating/PrioritizingReferences:
Christensen, B., & Kockrow, E. (2003).
Adult health nursing
(4th ed.). St.Louis: Mosby, p. 50.Perry, A., & Potter, P. (2004).
Clinical nursing skills & techniques
(5th ed.). St. Louis:Mosby, p. 1631.1602. A nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A Penrose drain is in place in the abdominal wound. Which nursingaction would be appropriate during the dressing change?1. Wearing clean gloves during the procedure
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PN~CD~Questions~1601-1700 -
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2. Advancing the drain by ¼ inch3. Checking the wound site for drainage from the drain4. Securing the drain by taping it firmly to bodyAnswer: 3Rationale:
Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red in color. Aseptic technique must be used when changing thedressing to prevent contamination of the wound, and sterile gloves are worn. The drainshould be checked for patency to provide an exit for the fluid and blood to promotehealing. The drainage needs to flow freely, and there should be no kinks in the drains.Curling, folding, or taping the drain prevents the flow of the drainage. The tube is notadvanced.Test-Taking Strategy:
Knowledge of the care of drains is necessary to answer thisquestion. Read each option carefully and visualize each option. Note that option 3 is theonly option that is a data collection action, the first step in the nursing process. Reviewnursing care to the client with a Penrose drain if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs:
Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReferences: Ignatavicius, D., & Workman, M. (2006).
Medical-surgical nursing:Critical thinking for collaborative care
(5th ed.). Philadelphia: W. B. Saunders, p. 350.Potter, P., & Perry, A. (2005).
Fundamentals of nursing
(6th ed.). St. Louis: Mosby, p.1507.1603. A nurse is assisting in caring for a client immediately following an abdominalsurgical procedure who lost a significant amount of blood during surgery. Which findingwould indicate a sign of a potential complication?1. Absent bowel signs2. A pulse rate of 90 beats/min3. A blood pressure of 120/70 mm Hg4. Increasing restlessnessAnswer: 4Rationale: Increasing restlessness noted in a client is a sign that requires continuous andclose monitoring because it could be indicative of a potential indication of acomplication, such as shock. Absent bowel sounds are a normal occurrence in theimmediate postoperative period following abdominal surgery. A blood pressure of 120/70 mm Hg with a pulse of 90 beats/min is a relatively normal sign.Test-Taking Strategy: Note the key words
immediately
,
abdominal
, and
lost a significant amount of blood
. Eliminate options 1, 2, and 3 because these are normal expectedfindings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications.Level of Cognitive Ability: AnalysisClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/Data CollectionContent Area: Fundamental SkillsReferences: Harkreader, H., & Hogan, M.A. (2004).
Fundamentals of nursing: Caring
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PN~CD~Questions~1601-1700 -
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and clinical judgment
(2nd ed.). Philadelphia: W.B. Saunders, p. 906.Ignatavicius, D., & Workman, M. (2006).
Medical-surgical nursing: Critical thinking for collaborative care
(5th ed.). Philadelphia: W.B. Saunders, p. 346.Perry, A., & Potter, P. (2004).
Clinical nursing skills & techniques
(5th ed.). St. Louis:Mosby, p. 982.Potter, P., & Perry, A. (2005).
Fundamentals of nursing
(6th ed.). St. Louis: Mosby, p.1642.1604. A nurse is changing the abdominal dressing on a postoperative client followingabdominal surgery. The nurse notes that the incision line is separated and notes theappearance of underlying tissue. Wound dehiscence is suspected.Which of the following is the appropriate initial nursing action?1. Ask the client to cough to verify the presence of dehiscence2. Apply a sterile dressing soaked with sterile normal saline to the wound3. Leave the incision open to the air 4. Apply a dry sterile dressing to the woundAnswer: 2Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signsand symptoms include increased drainage and the appearance of underlying tissue. Itusually occurs 6 to 8 days after surgery. The client should be instructed to remain quietand to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used tocover the wound. The physician needs to be notified.Test-Taking Strategy: Use the process of elimination. Eliminate option 1 becausecoughing will disrupt the exposed underlying tissue and organs. Eliminate option 3 because this action would expose the open wound and underlying tissue to infection.Eliminate option 4 next. A dry dressing will irritate the exposed body tissue. Reviewemergency care when dehiscence or evisceration occurs, if you had difficulty with thisquestion.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReferences: Harkreader, H., & Hogan, M.A. (2004).
Fundamentals of nursing: Caring and clinical judgment
(2nd ed.). Philadelphia: W.B. Saunders, pp. 621-622.Potter, P., & Perry, A. (2005).
Fundamentals of nursing
(6th ed.). St. Louis: Mosby, pp.1493-1494.1605. A nurse is preparing a client for surgery. Which of the following would be acomponent of the plan of care?1. Review the results of the preoperative laboratory studies2. Report any increases in blood pressure on the day of surgery3. Verify that the client has remained NPO for 24 hours before surgery4. Instruct the client to avoid oral hygiene on the morning of surgeryAnswer: 1Rationale:
The nurse needs to review the results of the preoperative laboratory studies
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