🔷 TPN is a high-alert nutritional infusion because it contains concentrated dextrose, amino acids, electrolytes, vitamins, and other additives.

🔷 It must be verified carefully against the provider’s prescription to prevent serious complications such as hyperglycemia, electrolyte imbalance, or fluid overload.

🔷 The safest rule is that two licensed nurses compare the TPN label with the order before hanging the bag.

🔷 This double-check helps confirm the correct client, formula, rate, additives, and expiration time.

🔷 TPN is usually administered through a central line using an infusion pump and strict aseptic technique.

It must be checked compared to the physician’s order by any 2 people.

🔷Any two people are not appropriate because TPN verification requires licensed clinical judgment.

🔷Unlicensed personnel cannot independently verify high-alert IV therapy.

It must be checked/compared to the physician’s order by an RN and pharmacist.

🔷The pharmacist prepares or verifies the TPN before it reaches the unit, but bedside hanging requires nursing verification.

🔷Facility policy typically requires two licensed nurses.

The physician must come to the bedside and hang the TPN him/herself.

🔷Physicians prescribe TPN but do not routinely hang it at the bedside.

🔷Hanging and monitoring TPN is a nursing responsibility.

🔶 A Jackson-Pratt drain works by creating gentle suction when the bulb is compressed.

🔶 Decreased drainage can be expected as the wound begins healing and fluid accumulation lessens.

🔶 The nurse should first verify that the bulb remains compressed and functioning properly.

🔶 If the drain is patent, the tubing is not kinked, and there are no signs of infection or swelling, the finding should be documented and monitored.

🔶 Sudden absence of drainage with pain, swelling, or loss of suction would require further action.

Notify the surgeon of a possible blockage and wait for orders.

🔶This is not the first action if the drain appears functional and drainage is simply decreasing.

🔶The nurse should assess the drain system before assuming blockage.

Replace the drain and notify the provider.

🔶Nurses do not replace JP drains independently.

🔶Drain replacement is a provider-managed procedure.

Remove the drain and notify the provider.

🔶The nurse should not remove a JP drain without a prescription.

🔶Removing it could interrupt wound healing and increase risk for fluid accumulation.

Instruct a staff member to notify a surgeon STAT

🔷 Evisceration is a surgical emergency because internal organs protrude through the wound opening.

🔷 The surgeon must be notified immediately because the client usually requires urgent operative repair.

🔷 Delegating notification allows the nurse to remain at the bedside and protect the exposed tissue.

🔷 Rapid communication helps prevent tissue drying, infection, shock, and further wound separation.

🔷 The nurse should stay with the client and continue emergency wound protection.

Obtain and monitor vital signs

🔷 Vital signs help identify early signs of shock, bleeding, infection, or physiologic instability.

🔷 Evisceration can cause anxiety, pain, fluid loss, and circulatory compromise.

🔷 Monitoring blood pressure, pulse, respiratory rate, oxygen saturation, and temperature helps guide urgent care.

🔷 Changes in vital signs should be reported promptly to the provider.

🔷 Continued assessment is essential until surgical intervention occurs.

Position the patient with knees flexed

🔷 The client should be placed in a low-Fowler’s or supine position with knees flexed.

🔷 Flexing the knees decreases tension on the abdominal incision.

🔷 Reduced abdominal strain helps prevent further protrusion of abdominal contents.

🔷 This position also promotes comfort and limits pulling on the wound edges.

🔷 The goal is to protect the exposed organs and reduce pressure on the incision.

Cover with moistened sterile dressings or sterile drape

🔷 The exposed organs must be covered with sterile dressings moistened with normal saline.

🔷 Moist sterile coverage prevents tissue drying and decreases contamination risk.

🔷 The nurse should avoid applying pressure directly to the exposed bowel.

🔷 Maintaining moisture helps preserve tissue viability until surgical repair.

🔷 This is one of the most important immediate nursing actions.

Attempt to push the bowel back into the abdominal cavity.

🔷The nurse should never attempt to reinsert exposed organs.

🔷This can cause tissue injury, contamination, perforation, and worsening complications.

Place the patient in high-Fowler’s.

🔷High-Fowler’s increases tension on the abdominal incision.

🔷This can worsen evisceration and increase protrusion of abdominal contents.

🔵 Stop suctioning immediately because a falling oxygen saturation indicates the patient is developing oxygen desaturation during the procedure.

🔵 Suctioning removes secretions but also temporarily removes oxygen from the airway, which can worsen hypoxia if continued.

🔵 After three passes, the nurse should provide supplemental oxygen and allow the patient time to recover.

🔵 Reassessment is needed to determine whether the patient’s oxygen saturation improves and whether further suctioning is still safe.

🔵 Patient safety takes priority over completely clearing secretions when signs of hypoxia appear.

Perform two more suction passes

🔵This can worsen oxygen desaturation because the patient is already showing signs of poor oxygenation.

🔵Additional passes should not be done until the patient is reoxygenated and reassessed.

Continue suctioning until the airway clears

🔵Continuous suctioning increases the risk of hypoxia, airway trauma, and cardiac dysrhythmias.

🔵Suctioning should be brief and interrupted when oxygen saturation drops.

Increase suction pressure and continue

🔵Higher suction pressure can damage airway mucosa and does not correct oxygen desaturation.

🔵The priority is oxygenation, not stronger suction pressure.

🟣 A hematoma is a localized collection of blood under intact skin or within soft tissue.

🟣 It commonly occurs after trauma, such as a fall, when small blood vessels rupture beneath the skin.

🟣 The hip is a common site for hematoma formation after impact because soft tissue can collect pooled blood.

🟣 The skin remains intact, but the area may appear swollen, bruised, tender, or discolored.

🟣 Documenting the finding as a hematoma accurately describes pooled blood beneath the skin.

Abrasion.

🟣An abrasion is a superficial scraping or rubbing away of the skin surface.

🟣 It involves broken skin, not pooled blood under intact skin.

Avulsion.

🟣An avulsion is tearing away of tissue, often leaving a flap or missing skin.

🟣This does not describe intact skin with blood collected underneath.

Laceration.

🟣A laceration is a cut or tear in the skin or tissue.

🟣The question describes intact skin, so this term does not fit.

🟢 This patient has the highest risk because advanced age, CHF, and 3+ pitting edema all decrease tissue tolerance.

🟢 Edema stretches the skin and reduces oxygen and nutrient delivery to tissues, making skin more vulnerable to breakdown.

🟢 CHF can impair circulation, which slows healing and increases the risk of pressure injury formation.

🟢 A 90-year-old patient also has thinner skin, reduced subcutaneous tissue, and decreased ability to tolerate prolonged pressure.

🟢 The combination of poor circulation, edema, and advanced age places this patient at greatest risk.

An ambulatory 88-year-old with dementia who is admitted with shingles.

🟢 Dementia and age increase risk, but ambulation reduces prolonged pressure exposure.

🟢 Shingles affects skin integrity, but this patient is not described as immobile or edematous.

A 6-month-old with gastroenteritis who vomits and has diarrhea.

🟢Moisture and dehydration can increase skin risk, especially in the diaper area.

🟢 However, this risk is lower than severe edema with impaired circulation in an older adult.

A 71-year-old with a colostomy and feeding tube who goes to physical therapy daily.

🟢 A feeding tube and colostomy may indicate nutritional and skin-care needs.

🟢 Daily physical therapy suggests mobility, which lowers pressure ulcer risk.

🟠 Restlessness is an early sign of hypoxia because the brain is very sensitive to reduced oxygen levels.

🟠 When oxygen delivery decreases, the patient may first show anxiety, agitation, confusion, or inability to remain calm.

🟠 Early recognition is important because hypoxia can progress quickly if not corrected.

🟠 The nurse should assess respiratory status, oxygen saturation, lung sounds, and airway patency.

🟠 Restlessness should never be ignored in a patient at risk for oxygenation problems.

Cyanosis.

🟠 Cyanosis is a late sign of hypoxia and indicates significant oxygen deprivation.

🟠 Waiting for cyanosis can delay urgent intervention.

Delirium.

🟠Delirium can occur with worsening hypoxia, especially in older adults.

🟠 It is not usually the earliest finding compared with restlessness.

Bradycardia.

🟠Bradycardia is generally a late and serious sign of hypoxia.

🟠 Early hypoxia more commonly causes tachycardia, restlessness, and anxiety.

🔴 Wound dehiscence is the partial or complete separation of the wound edges after surgery.

🔴 Seeing the suture line separating is a direct sign that the incision is opening.

🔴 This is a serious postoperative complication because it can progress to evisceration if abdominal contents protrude.

🔴 The nurse should protect the wound, reduce strain on the incision, and notify the provider promptly.

🔴Early recognition prevents further tissue damage, infection, and emergency complications.

Increased pallor at the surgical site.

🔴Pallor may suggest reduced blood flow or poor perfusion.

🔴 It does not directly indicate that the wound edges are separating.

Excessive gas with abdominal pain.

🔴Gas and abdominal discomfort may occur after abdominal surgery due to slowed bowel activity.

🔴These findings do not define wound dehiscence.

Complaint of constipation.

🔴Constipation can increase abdominal pressure and strain the incision.

🔴However, it is not the finding that confirms dehiscence.