SAUNDERS NCLEX 8TH EDITION EXAM QUESTIONS WITH CORRECT ANSWERS

SAUNDERS NCLEX 8TH EDITION EXAM QUESTIONS WITH CORRECT ANSWERS Rationale: increasing restlessness is a sign that requires a continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A client who has had abdominal surgery complains of feeling as though " something gave way" in the incisional sight. The nurse remove the dressing and notes of the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound F. Place the client in a supine position without a pillow under the head - Answer-A,B,C,D Rationale: wound dehiscence it's the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with a client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse place is the client in a low Fowlers position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. A client who has undergone pre-admission testing has blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeons office by the nurse, knowing that it could cause surgery to be postponed? A. Hemoglobin, 8.0 g/dL B. Sodium, 145 mEq/L C. Serum creatinine, 0.8 mg/dL D. Platelets, 210,000 cells/mm - Answer-A. Hemoglobin, 8.0 g/dL Rationale: routine screening test include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon The nurse received a telephone call from the post anesthesia care unit stating that a client has been transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway