The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?

Correct Answer: B

Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.

Correct Answer: B

Rationale: The correct answer is B. In the discharge teaching plan for a client after cardiac surgery, it is important for the nurse to include education on monitoring for signs of complications, such as notifying the physician if a painless lump is felt at the top of the chest incision. This could potentially indicate a seroma or hematoma, which may require medical attention. By educating the client on this specific point, the nurse helps to promote early detection and prompt management of any post-operative issues, which contributes to better outcomes for the client. The other options mentioned are important aspects of post-cardiac surgery care but do not address the specific concern of a painless lump at the chest incision site.

Correct Answer: B

Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.

Correct Answer: B

Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.

Correct Answer: C

Rationale: When a neurologist asks a patient to smile, they are testing the function of the facial nerve, Cranial Nerve VII (CN VII). CN VII controls the muscles of facial expression, including the muscles required for smiling. If there is weakness or paralysis on one side of the face when the patient tries to smile, it may indicate a problem with CN VII function, such as Bell's palsy or a lesion affecting the facial nerve.