Matching questions
1-20 of 20
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Four days after abdominal surgery, the patient is getting out of bed and feels
something "pop" in his abdominal wound. An increase in amount of drainage from the
wound is seen, and further examination shows that the sutured incision is now partially
open, with tissue protruding from the wound. Which are the priority nursing
interventions? (Select all that apply.)
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze.
c. Apply a binder to pull the wound edges together and provide support to the
edges.
d. Notify the surgeon.
e. Allow the area to be exposed to air until all of the drainage has stopped.
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Answer: b, d
This is likely to be an evisceration of the surgical wound and, as such, may
require surgical intervention. The normal saline keeps the wound and tissue
moist until they can be evaluated by the surgeon. Steri-Strips can be used
to reinforce a closed wound when sutures or staples are removed but are
not used to try to close a wound that has opened and has tissue protruding
, through. A binder is used to support a closed incision and should not be
applied to a wound with tissue protruding. Allowing the area to be
exposed puts the patient at risk for infection.
While conducting a preoperative health assessment, the nurse is informed about a
patient's preexisting heart problem. What postoperative interventions should be
included in the plan of care for this patient to address the heart issue?
a. Perform a systematic head-to-toe assessment every 4 hours.
b. Monitor breath sounds and oxygen saturation.
c. Administer pain medications as needed.
d. Monitor the electrocardiogram (ECG), apical pulse, and capillary refill.
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Answer: d
Monitoring the patient's ECG, pulse, and capillary refill allows the nurse to
assess the cardiovascular system. A head-to-toe assessment every 4 hours
does not provide specific information for a focused assessment of the
heart. Monitoring breath sounds and oxygenation saturation provides
information about the respiratory system. Administering pain medication is
necessary but does not give the nurse specific information about the heart.
The nurse provided preoperative teaching about pain management to a patient
scheduled for surgery. Which postoperative activity by the patient indicates the
effectiveness of teaching?
a. Doing something enjoyable, such as relaxing and reading a book
b. Requesting pain medication when no longer able to tolerate the pain
c. Removing the postoperative dressing to see the surgical incision
d. Refusing to wear antiembolism stockings while still on bed rest
Give this one a try later!
1-20 of 20
Click a definition to match it with a term
Four days after abdominal surgery, the patient is getting out of bed and feels
something "pop" in his abdominal wound. An increase in amount of drainage from the
wound is seen, and further examination shows that the sutured incision is now partially
open, with tissue protruding from the wound. Which are the priority nursing
interventions? (Select all that apply.)
a. Apply Steri-Strips to close the wound edges.
b. Cover the wound with saline-moistened gauze.
c. Apply a binder to pull the wound edges together and provide support to the
edges.
d. Notify the surgeon.
e. Allow the area to be exposed to air until all of the drainage has stopped.
Give this one a try later!
Answer: b, d
This is likely to be an evisceration of the surgical wound and, as such, may
require surgical intervention. The normal saline keeps the wound and tissue
moist until they can be evaluated by the surgeon. Steri-Strips can be used
to reinforce a closed wound when sutures or staples are removed but are
not used to try to close a wound that has opened and has tissue protruding
, through. A binder is used to support a closed incision and should not be
applied to a wound with tissue protruding. Allowing the area to be
exposed puts the patient at risk for infection.
While conducting a preoperative health assessment, the nurse is informed about a
patient's preexisting heart problem. What postoperative interventions should be
included in the plan of care for this patient to address the heart issue?
a. Perform a systematic head-to-toe assessment every 4 hours.
b. Monitor breath sounds and oxygen saturation.
c. Administer pain medications as needed.
d. Monitor the electrocardiogram (ECG), apical pulse, and capillary refill.
Give this one a try later!
Answer: d
Monitoring the patient's ECG, pulse, and capillary refill allows the nurse to
assess the cardiovascular system. A head-to-toe assessment every 4 hours
does not provide specific information for a focused assessment of the
heart. Monitoring breath sounds and oxygenation saturation provides
information about the respiratory system. Administering pain medication is
necessary but does not give the nurse specific information about the heart.
The nurse provided preoperative teaching about pain management to a patient
scheduled for surgery. Which postoperative activity by the patient indicates the
effectiveness of teaching?
a. Doing something enjoyable, such as relaxing and reading a book
b. Requesting pain medication when no longer able to tolerate the pain
c. Removing the postoperative dressing to see the surgical incision
d. Refusing to wear antiembolism stockings while still on bed rest
Give this one a try later!
