Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).
A. Place the client in a low Fowler's position with the knees bent.
Can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
B. Cover the client's wound with a sterile saline-soaked dressing.
Is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
C. Notify the surgeon about the finding.
Is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
D. Prepare the client for transfer to surgery.
Is the correct sequence of steps in this situation.Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN VATI Adult Medical Surgical S 2019 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.
Similar Questions
A nurse is caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply.).
A. Encourage the client to try to void.
Is appropriate to assess postoperative urinary function after transurethral resection of the prostate (TURP). It helps monitor the return of normal bladder function.
B. Secure the drainage tube to the client's thigh.
Is not necessary and could potentially cause discomfort and increased risk of tube dislodgment. Securing the tube properly to the bed or clothing is a more appropriate method.
C. Monitor the client's urine output every 2 hr.
Is essential to assess urinary function, and fluid balance, and identify any potential complications such as urinary retention or excessive bleeding.
D. Administer antispasmodics for bladder spasms.
Helps alleviate discomfort and prevent spasms after TURP. Bladder spasms can be common after the procedure, and antispasmodics can aid in managing them.
E. Perform intermittent bladder irrigation.
Is necessary to keep the catheter patent and prevent clot formation in the urinary tract. It helps maintain proper drainage and prevents complications.
Full Explanation
Choice A rationale:
Is appropriate to assess postoperative urinary function after transurethral resection of the prostate (TURP). It helps monitor the return of normal bladder function.
Choice B rationale:
Is not necessary and could potentially cause discomfort and increased risk of tube dislodgment. Securing the tube properly to the bed or clothing is a more appropriate method.
Choice C rationale:
Is essential to assess urinary function, and fluid balance, and identify any potential complications such as urinary retention or excessive bleeding.
Choice D rationale:
Helps alleviate discomfort and prevent spasms after TURP. Bladder spasms can be common after the procedure, and antispasmodics can aid in managing them.
Choice E rationale:
Is necessary to keep the catheter patent and prevent clot formation in the urinary tract. It helps maintain proper drainage and prevents complications.
A nurse is instructing a client who has cancer about precautions to take while undergoing chemotherapy. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will wear gloves when I change my cat's litter box.".
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
B. "I will take my temperature once each week.".
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
C. "I will be able to attend my favorite singer's concert.".
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
D. "I will allow my toothbrush to dry completely between each use.".
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.
Full Explanation
Choice A rationale:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.
A nurse is caring for a client who has a deep vein thrombosis and a prescription for heparin. For which of the following findings should the nurse withhold the medication and notify the provider?
A. INR 0.8, aPTT 85 seconds.
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
B. INR 2, aPTT 60 seconds.
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.
Full Explanation
Choice A rationale:
An INR (International Normalized Ratio) of 0.8 is within the normal range for someone not on anticoagulation therapy. The aPTT (activated partial thromboplastin time) of 85 seconds is prolonged, but it is not a reason to withhold heparin in itself. Therefore, the nurse should not withhold the medication for these values.
Choice B rationale:
An INR of 2 indicates the client's blood is taking twice as long to clot compared to the average, which can increase the risk of bleeding. The aPTT of 60 seconds is within the normal range. However, the elevated INR suggests the client might be overly anticoagulated, so the nurse should withhold the medication and notify the provider.