A patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed.the nurse removes the dressing and finds that dehiscence of the wound has occurred.what nursing action should be implemented first?

Correct Answer: A

Rationale: The correct answer is A: Cover the wound with sterile dressings saturated with normal saline. This action helps to maintain a moist environment for wound healing and prevent further contamination. The step-by-step rationale is: 1) Covering the wound with sterile dressings helps protect the wound from infection and further trauma. 2) Saturating the dressings with normal saline helps keep the wound moist, promoting healing. 3) This immediate action is crucial in preventing complications such as infection and further wound dehiscence. Summary of other choices: B: Notifying the surgeon immediately is important, but covering the wound to protect it should be done first. C: Applying pressure to the wound can further damage the tissue and should not be done. D: Placing the patient in Trendelenburg position is not necessary for wound dehiscence and does not address the immediate need to protect the wound.

Correct Answer: B

Rationale: The correct answer is B: date of birth. It is essential to obtain the patient's date of birth for accurate identification and to ensure the correct patient receives the appropriate care. This information is crucial for confirming the patient's identity and preventing medical errors. Explanation for Incorrect Choices: A: Address - While obtaining the patient's address is important for communication and follow-up purposes, it is not a critical piece of information that must be obtained during the admission process. C: Admitting physician - Knowing the admitting physician is important for coordination of care, but it is not crucial information that must be obtained directly from the patient. D: Symptoms experienced - While knowing the symptoms experienced by the patient is important for medical history and assessment, it is not a piece of information that must be obtained directly from the patient during the admission process.

Correct Answer: B

Rationale: The correct answer is B: planning. Planning in the nursing process involves setting goals and outcomes, which the nurse is doing by discussing expected outcomes with the patient and family. This step helps establish a direction for the care to be provided. Diagnosing (A) involves analyzing data to identify health problems. Implementing (C) is the actual carrying out of the planned interventions. Evaluating (D) involves determining if the goals were met. In this scenario, the nurse is focusing on setting goals, making B the most appropriate answer.

Correct Answer: B

Rationale: The correct answer is B: QD (daily) because the Joint Commission's "Do Not Use" list includes this abbreviation due to its potential for misinterpretation as QID (four times a day) or QOD (every other day). QD is ambiguous and can lead to medication errors. A, C, and D are not on the list as they are commonly accepted and understood medical abbreviations.

Correct Answer: B

Rationale: The correct answer is B: preventing illness. Teaching breast self-examination helps in early detection of breast abnormalities, leading to early diagnosis and treatment, thus preventing the development of serious illnesses like breast cancer. Promoting health (A) focuses on enhancing overall well-being and preventing diseases, but breast self-examination specifically targets illness prevention. Restoring health (C) involves interventions to return an individual to their optimal state of health after illness, not preventing illness. Facilitating coping with disability and death (D) involves supporting individuals dealing with existing health challenges, not necessarily preventing future illnesses.