a client returns from surgery after having a colon resection the nurse is performing his assessment and notes the wound edges have separated this cond a client returns from surgery after having a colon resection the nurse is performing his assessment and notes the wound edges have separated this cond
Logo

Nursing Elites

NCLEX NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:

Correct answer: Dehiscence

Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.

2. A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?

Correct answer: Client will identify life stressors that may be contributing to depression

Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management. Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.

3. The client is receiving an MAOI. Which foods should the nurse caution the client to avoid?

Correct answer: C: Cheese, beer, and products with chocolate

Rationale: The correct answer is C. When a client is receiving a monoamine oxidase inhibitor (MAOI), they should avoid foods high in tyramine to prevent a hypertensive crisis. Cheese, beer, and products with chocolate are rich in tyramine and can interact with MAOIs, leading to a dangerous rise in blood pressure. Choices A, B, and D do not contain high levels of tyramine and are not typically restricted when taking MAOIs.

4. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

Correct answer: Administer the feeding as ordered

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

5. A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?

Correct answer: Wash the area gently with water and pat dry

Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.

Similar Questions

Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?
A client who has been told she needs a hysterectomy for cervical cancer reports being upset about being unable to have a third child. Which action would the nurse take?
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99