A client had a hemicolectomy performed two days ago. Today, the nurse assessed the incision and discovered a small part of the abdominal viscera protruding through the incision. This complication of wound healing is known as:

Correct Answer: D

Rationale: Excoriation is an abrasion of the epidermis, or of any organ coating of the body, caused by trauma, chemicals, burns, or other causes. Dehiscence is a partial to complete separation of the wound edges with no abdominal tissue protrusion. Decortication is removal of the surface layer of an organ or structure, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. Evisceration occurs when the incision separates and the contents of the cavity spill out.

Correct Answer: B

Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.

Correct Answer: D

Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.

Correct Answer: C

Rationale: In conducting a primary survey on a trauma patient, a brief neurologic assessment is considered one of the priority elements. This is because assessing the patient's level of consciousness, orientation, and pupillary response provides crucial information about their neurological status and helps identify any potential brain injury or impairment. A complete set of vital signs, while important, comes after the primary survey and should not delay immediate interventions. Palpation and auscultation of the abdomen are part of the secondary survey, which follows the primary survey in trauma care. Initiation of pulse oximetry is also important but falls under the secondary survey as it assesses oxygenation status. Educationally, understanding the prioritization of assessments in trauma care is essential for nurses and healthcare providers to effectively and efficiently manage patients in critical situations. Emphasizing the significance of a brief neurologic assessment in the primary survey reinforces the importance of quickly identifying life-threatening conditions and initiating appropriate interventions to optimize patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct nursing action is to have the student breathe into a paper bag (Option C). This is because the symptoms described indicate possible hyperventilation, which can lead to respiratory alkalosis. Breathing into a paper bag helps to rebreathe exhaled carbon dioxide, which can help restore the acid-base balance in the body. Option A (Notify the physician immediately) is incorrect because the situation does not warrant immediate physician notification as it is a common nursing intervention that can be implemented without a physician's order. Option B (Administer supplemental oxygen) is incorrect because supplemental oxygen is not indicated for hyperventilation. In fact, giving oxygen may worsen the respiratory alkalosis by decreasing carbon dioxide levels further. Option D (Obtain an order for an anxiolytic medication) is also incorrect because the priority in this situation is to address the respiratory alkalosis caused by hyperventilation, not anxiety. Anxiolytic medications are not the first-line treatment for hyperventilation. In an educational context, understanding the rationale behind interventions for respiratory alkalosis is crucial for nurses caring for patients experiencing this condition. Nurses need to recognize the signs and symptoms of respiratory alkalosis and implement appropriate nursing interventions promptly to restore the acid-base balance in the body. This knowledge is essential for providing safe and effective patient care in various clinical settings.