a post operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement upon inspection the nurse notices

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

A. The client's incision site has eviscerated
B. The client's incision site has lacerated
C. The client's incisional site is approximated
D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

2. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

A. Administer antibiotics to the client
B. Increase the client's protein intake
C. Teach relaxation breathing to reduce the client's pain
D. Provide the client with anti-pyretic therapy

Correct answer: A

Rationale:

3. A client has AIDS. Which of these findings indicate possible infection?

A. Respirations; 22 breaths per minute
B. Client ambulates 20 feet
C. Purulent drainage
D. Oxygen saturation; 97% on room air

Correct answer: C

Rationale:

4. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
C. The UAP carefully empties the indwelling catheter bag
D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.