Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:

Correct Answer: A

Rationale: Nurse Maria should immediately cover the wound with a moist sterile dressing to protect the exposed tissue and prevent infection. This action will help maintain the moisture needed for wound healing and reduce the risk of further complications. It is important to cover the exposed area to prevent any external contaminants from entering the wound, while also keeping the area moist to promote healing. It is crucial to seek medical attention promptly to address the situation and ensure proper care for the patient.

Correct Answer: B

Rationale: High cholesterol levels are closely linked to the development of myocardial infarction (MI), also known as a heart attack. Elevated levels of cholesterol in the blood can lead to the buildup of plaque in the coronary arteries, causing atherosclerosis. This buildup can restrict blood flow to the heart muscle, potentially resulting in a heart attack. Managing and controlling cholesterol levels through lifestyle changes and medications can help reduce the risk of MI.

Correct Answer: A

Rationale: The symptoms Emil is experiencing, such as circumoral tingling, positive Chvostek's sign (facial muscle spasm when the facial nerve is tapped), and positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated), are characteristic signs of hypocalcemia. Hypocalcemia commonly occurs after thyroidectomy due to inadvertent damage or removal of the parathyroid glands. These glands regulate calcium levels in the body by secreting parathyroid hormone (PTH). Therefore, the symptoms Emil is exhibiting are likely due to the overstimulation of the parathyroid hormone in response to decreased calcium levels after the thyroidectomy. Insufficient iodine intake or overuse of radioactive iodine gland would not be the most likely explanations for his symptoms.

Correct Answer: D

Rationale: In this scenario, the nurse's first action should be to obtain a Doppler ultrasound device to assess the pedal pulses. If the nurse was unable to palpate the pedal pulses initially, the use of a Doppler can help in accurately identifying the pulses. It is essential to confirm the absence or presence of peripheral pulses before taking any further actions. This will provide crucial information for the physician to determine the appropriate course of treatment. Conducting a Doppler assessment will assist in evaluating the severity of the situation and guide the next steps in the patient's care plan.

Correct Answer: A

Rationale: In this scenario where the client with type I diabetes mellitus is exhibiting confusion, light-headedness, and aberrant behavior, indicating hypoglycemia, the first-line treatment would be administering I.M. or subcutaneous glucagon. Glucagon helps to rapidly increase blood sugar levels by stimulating the liver to release stored glucose. This is crucial in situations where the client is conscious but unable to take oral carbohydrates, such as in cases of severe hypoglycemia with altered mental status. Administration of glucagon helps to quickly raise blood sugar levels and prevent further deterioration in the client's condition. Options B, C, and D are not the initial interventions in this situation and may not be as effective in rapidly correcting hypoglycemia in a client who is exhibiting signs of confusion and aberrant behavior.