Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
A. Cover the wound with sterile, saline-soaked gauze.
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
B. Raise the head of the bed to a 45° angle.
C. Hold gentle, direct pressure on the protruding organ
D. Place the client's knees in an extended position.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
Similar Questions
A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?
A. History of ectopic pregnancy
B. Vaginal yeast infection
C. Hypertension
The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of cardiovascular events such as stroke, heart attack, or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.
D. Irregular menses
Full Explanation
The correct answer is C.
Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of
cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
A. Document the infiltration.
B. Stop the infusion.
The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
C. Elevate the arm.
D. Apply a warm compress.
Full Explanation
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider?
Select all that apply.
A. Blood pressure
The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
B. Mental confusion
The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. Cold, clammy skin
The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
D. Sodium level
The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
E. Pain
While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
F. Heart Rate
The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
G. Serum amylase level
The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.
H. Respiratory status
The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
I. Urine output
The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
J. Temperature
The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
Full Explanation
A. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
B. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
D. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
E. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
F. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
G. The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.
H. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
I. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
J. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.