The client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

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Question 1 of 5

The client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

Correct Answer: B

Rationale: A saturated abdominal dressing is a critical finding that may indicate active bleeding or wound complications. Immediate intervention is necessary to prevent further complications, such as hypovolemic shock or infection. Absent bowel sounds, though abnormal, are a common post-operative finding and do not require immediate intervention. Pain level of 8/10 can be managed effectively with appropriate pain control measures and does not indicate an urgent issue. A temperature of 100.4°F is slightly elevated but may be a normal post-operative response to surgery and does not typically require immediate intervention unless accompanied by other concerning signs or symptoms.

Question 2 of 5

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

Correct Answer: B

Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.

Question 3 of 5

A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?

Correct Answer: A

Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.

Question 4 of 5

An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

Correct Answer: D

Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.

Question 5 of 5

A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?

Correct Answer: B

Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.

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