,1. The nurse is monitoring a client's surgical incision and notes an increase in the
amount of drainage, a separation of the incision line, and the appearance of
underlying tissue. The client reports discomfort at the incision site, and the nurse
observes that the wound edges are no longer approximated. Which of the
following is an appropriate action for the nurse to take?
A. Apply a dry sterile dressing and reassess the incision in 1 hour.
B. Apply a sterile, normal-saline soaked dressing to the wound.
C. Attempt to gently approximate the wound edges with sterile gloves.
D. Apply an abdominal binder tightly over the surgical incision.
Correct Answer: B. Apply a sterile, normal-saline soaked dressing to the
wound.
Rationale: A sterile dressing soaked with normal saline helps protect exposed
underlying tissue and prevents the wound from drying while the client receives
further medical evaluation. Separation of the incision with visible underlying tissue
indicates wound dehiscence and possible evisceration, which requires immediate
intervention. The nurse should not attempt to push the exposed tissue back into the
wound or manually approximate the wound edges. The surgeon or primary health
care provider should be notified promptly because this is a postoperative emergency.
2. The nurse is providing preoperative instructions to a client who is scheduled for
surgery to correct spinal curvature. The nurse explains that postoperative
positioning and movement will be important for preventing complications and
protecting the surgical repair. Which of the following statements by the client best
demonstrates a correct understanding of the teaching?
A. "I will remain completely still in bed until my provider tells me otherwise."
B. "I will bend forward frequently to prevent stiffness in my back."
C. "I will show you the method of turning I will use after surgery."
D. "I will sit upright without assistance as soon as I return from surgery."
Correct Answer: C. "I will show you the method of turning I will use after
surgery."
,Rationale: Demonstrating the prescribed method of turning shows that the client
understands how to move while protecting the spinal surgical site. Proper turning
techniques help maintain spinal alignment and reduce the risk of injury to the
surgical repair. The client should follow the prescribed method rather than bending,
twisting, or moving independently. Demonstration also allows the nurse to identify
and correct misunderstandings before surgery.
3. The nurse is assessing a postoperative client who has advanced cognitive
impairment. The client is unable to clearly describe the location or severity of pain
and provides inconsistent verbal responses during the assessment. Which of the
following actions by the nurse is most effective when assessing the client's level of
pain?
A. Ask the client's family member to determine whether pain is present.
B. Assume the client has no pain unless the client reports it verbally.
C. Monitor the client's body language, facial expressions, emotional status, and
consolability.
D. Administer a prescribed analgesic only when the client specifically requests it.
Correct Answer: C. Monitor the client's body language, facial expressions,
emotional status, and consolability.
Rationale: Clients with advanced cognitive impairment may be unable to
communicate pain reliably through verbal descriptions. Behavioral indicators such as
facial expressions, body movements, emotional changes, and response to comforting
measures can provide important information about pain. Pain should not be assumed
to be absent simply because the client cannot describe it. A comprehensive
behavioral assessment allows the nurse to recognize and appropriately manage pain.
4. The nurse is caring for a client who has diabetes mellitus and reports sharp,
burning pain in the bilateral lower extremities. The client describes the pain as
worse at night and reports a tingling sensation in both feet. The nurse recognizes
, that these symptoms are associated with nerve involvement related to diabetes.
The nurse understands that the client may be experiencing which type of pain?
A. Visceral pain
B. Somatic pain
C. Referred pain
D. Neuropathic pain
Correct Answer: D. Neuropathic pain
Rationale: Neuropathic pain results from damage or dysfunction of nerves and is
commonly associated with diabetes mellitus. Sharp, burning, shooting, and tingling
sensations in the extremities are characteristic manifestations. Diabetic peripheral
neuropathy commonly affects the lower extremities and may become more
noticeable at night. Recognizing the pain as neuropathic helps the nurse anticipate
appropriate assessment and management.
5. The nurse is caring for a client who is scheduled to have surgery the following
day. During the preoperative assessment, the nurse reviews the client's medical
and family history for factors that could increase the risk of complications during
anesthesia. Which of the following findings requires notification of the primary
health care provider (PHCP)?
A. The client reports mild anxiety about the upcoming surgery.
B. The client reports a family history of high fever during a surgical procedure.
C. The client reports that a sibling experienced nausea after anesthesia.
D. The client reports having difficulty sleeping before previous procedures.
Correct Answer: B. The client reports a family history of high fever during a
surgical procedure.
Rationale: A family history of an unexplained high fever during anesthesia may
indicate susceptibility to malignant hyperthermia, a potentially life-threatening
anesthetic reaction. The PHCP and anesthesia team need to be notified before
surgery so appropriate precautions can be taken. Malignant hyperthermia can cause
severe muscle rigidity, hyperthermia, metabolic abnormalities, and cardiovascular
amount of drainage, a separation of the incision line, and the appearance of
underlying tissue. The client reports discomfort at the incision site, and the nurse
observes that the wound edges are no longer approximated. Which of the
following is an appropriate action for the nurse to take?
A. Apply a dry sterile dressing and reassess the incision in 1 hour.
B. Apply a sterile, normal-saline soaked dressing to the wound.
C. Attempt to gently approximate the wound edges with sterile gloves.
D. Apply an abdominal binder tightly over the surgical incision.
Correct Answer: B. Apply a sterile, normal-saline soaked dressing to the
wound.
Rationale: A sterile dressing soaked with normal saline helps protect exposed
underlying tissue and prevents the wound from drying while the client receives
further medical evaluation. Separation of the incision with visible underlying tissue
indicates wound dehiscence and possible evisceration, which requires immediate
intervention. The nurse should not attempt to push the exposed tissue back into the
wound or manually approximate the wound edges. The surgeon or primary health
care provider should be notified promptly because this is a postoperative emergency.
2. The nurse is providing preoperative instructions to a client who is scheduled for
surgery to correct spinal curvature. The nurse explains that postoperative
positioning and movement will be important for preventing complications and
protecting the surgical repair. Which of the following statements by the client best
demonstrates a correct understanding of the teaching?
A. "I will remain completely still in bed until my provider tells me otherwise."
B. "I will bend forward frequently to prevent stiffness in my back."
C. "I will show you the method of turning I will use after surgery."
D. "I will sit upright without assistance as soon as I return from surgery."
Correct Answer: C. "I will show you the method of turning I will use after
surgery."
,Rationale: Demonstrating the prescribed method of turning shows that the client
understands how to move while protecting the spinal surgical site. Proper turning
techniques help maintain spinal alignment and reduce the risk of injury to the
surgical repair. The client should follow the prescribed method rather than bending,
twisting, or moving independently. Demonstration also allows the nurse to identify
and correct misunderstandings before surgery.
3. The nurse is assessing a postoperative client who has advanced cognitive
impairment. The client is unable to clearly describe the location or severity of pain
and provides inconsistent verbal responses during the assessment. Which of the
following actions by the nurse is most effective when assessing the client's level of
pain?
A. Ask the client's family member to determine whether pain is present.
B. Assume the client has no pain unless the client reports it verbally.
C. Monitor the client's body language, facial expressions, emotional status, and
consolability.
D. Administer a prescribed analgesic only when the client specifically requests it.
Correct Answer: C. Monitor the client's body language, facial expressions,
emotional status, and consolability.
Rationale: Clients with advanced cognitive impairment may be unable to
communicate pain reliably through verbal descriptions. Behavioral indicators such as
facial expressions, body movements, emotional changes, and response to comforting
measures can provide important information about pain. Pain should not be assumed
to be absent simply because the client cannot describe it. A comprehensive
behavioral assessment allows the nurse to recognize and appropriately manage pain.
4. The nurse is caring for a client who has diabetes mellitus and reports sharp,
burning pain in the bilateral lower extremities. The client describes the pain as
worse at night and reports a tingling sensation in both feet. The nurse recognizes
, that these symptoms are associated with nerve involvement related to diabetes.
The nurse understands that the client may be experiencing which type of pain?
A. Visceral pain
B. Somatic pain
C. Referred pain
D. Neuropathic pain
Correct Answer: D. Neuropathic pain
Rationale: Neuropathic pain results from damage or dysfunction of nerves and is
commonly associated with diabetes mellitus. Sharp, burning, shooting, and tingling
sensations in the extremities are characteristic manifestations. Diabetic peripheral
neuropathy commonly affects the lower extremities and may become more
noticeable at night. Recognizing the pain as neuropathic helps the nurse anticipate
appropriate assessment and management.
5. The nurse is caring for a client who is scheduled to have surgery the following
day. During the preoperative assessment, the nurse reviews the client's medical
and family history for factors that could increase the risk of complications during
anesthesia. Which of the following findings requires notification of the primary
health care provider (PHCP)?
A. The client reports mild anxiety about the upcoming surgery.
B. The client reports a family history of high fever during a surgical procedure.
C. The client reports that a sibling experienced nausea after anesthesia.
D. The client reports having difficulty sleeping before previous procedures.
Correct Answer: B. The client reports a family history of high fever during a
surgical procedure.
Rationale: A family history of an unexplained high fever during anesthesia may
indicate susceptibility to malignant hyperthermia, a potentially life-threatening
anesthetic reaction. The PHCP and anesthesia team need to be notified before
surgery so appropriate precautions can be taken. Malignant hyperthermia can cause
severe muscle rigidity, hyperthermia, metabolic abnormalities, and cardiovascular
