The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, "I felt something ‘give way' when I coughed." What is the nurse's best response?
a. "It is good that you are coughing and deep-breathing to prevent pneumonia."
b. "That is a normal feeling in the incision whenever you are moving."
c. "Be sure to splint the incision with a pil-low or your hands when you cough."
d. "Lie down flat on the bed with your knees up and let me examine your incision."
D
Although wound dehiscence is not a common complication after surgery, it is usually painless and the client feels as if something has split or given way. This frequently occurs after coughing. Any client report of such a sensation should be assessed immediately.
You might also like to view...
A client with mastoiditis is admitted to your unit prior to undergoing a radical mastoidectomy. What do you know is a nursing priority postoperatively?
A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal
When one is seeking to achieve cultural competence, what is the first step one must undertake?
1. knowledge of other cultures 2. ability to speak other languages 3. clarification of one's own values 4. attitude of appreciation
When the Goodenough-Harris Drawing Test is administered to a child, the evaluator principally observes the:
a. presence and form of body parts. b. gender and race of the person drawn. c. approximate age and posture of the person drawn. d. length of time needed to draw a stick man.
As you come back from lunch, Keelan, another nursing assistant, tells you that he ambulated Mr. Jacobs for you while you were gone. Keelan asks you to record it in Mr. Jacobs's flowchart for him while he goes to lunch. What will you do?
A. Thank him and sign Keelan's name on the patient's flowchart. B. Ask Keelan to document his work before he leaves for lunch. C. Write that Mr. Jacobs was ambulated in the hall and sign your name. D. Have the RN document that Mr. Jacobs was ambulated by another nursing assistant.