Question

A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

Answer 1

Correct Answers:

Obtain bottles of warm. sterile 0.9% sodium chloride solution.

Rationale :

🩺 A wound evisceration occurs when internal organs protrude through a surgical incision, making it a medical emergency.

🩺 The priority is to protect the exposed viscera from drying and contamination by covering them with sterile dressings moistened with warm 0.9% sodium chloride.

🩺 Moistening prevents tissue damage and maintains viability of the organs until surgical repair can be performed.

🩺 The client should also be placed in a low-Fowler’s position with knees flexed to reduce abdominal pressure.

🩺 The nurse must stay with the client, monitor for shock, and notify the provider immediately.

❌ Place the client in left lateral recumbent position

This position does not reduce abdominal strain effectively. The preferred position is low-Fowler’s with knees flexed.

❌ Attempt to reinsert the protruding viscera

The nurse should never attempt to push organs back inside. This can cause further injury and contamination.

❌ Apply a firm pressure dressing across the client's abdomen

Applying pressure can damage exposed organs. The dressing should be loose, sterile, and moistened—not tight.

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Answer 2

Correct Answers

Blank 1 Correct Option: myocardial infarction
Blank 2 Correct Option: troponin levels

Rationale :

🫀 Why myocardial infarction is correct

🫀 The client’s chest tightness radiating to the left arm, shortness of breath, diaphoresis, and anxiety are classic warning signs of acute coronary syndrome.

🫀 At 0830, the chest pain decreased only from 7/10 to 5/10 after nitroglycerin, meaning the pain did not fully resolve. Persistent chest pain after nitroglycerin is concerning because stable angina usually improves with rest and nitroglycerin.

🫀 By 1100, the client still had chest tightness rated 5/10, along with shortness of breath and diaphoresis, showing that myocardial oxygen supply is still inadequate.

🫀 The provider initiated thrombolytic therapy at 1200, which strongly supports concern for an evolving clot-related coronary artery blockage.

🫀 These findings together indicate the client is at risk for, or already progressing toward, myocardial infarction, where prolonged ischemia causes death of heart muscle tissue.

🫀 Why troponin levels is correct

🫀 Troponin is a cardiac biomarker released into the blood when myocardial cells are injured.

🫀 The client’s Troponin T increased from 0.08 ng/mL to 0.2 ng/mL, which moved from near-normal to elevated above the reference range.

🫀 The client’s Troponin I increased from 0.01 ng/mL to 0.1 ng/mL, also rising above the expected reference range.

🫀 Rising troponin over time is more concerning than a single value because it shows ongoing myocardial damage.

🫀 In this case, the elevated troponins match the clinical picture of persistent chest pain, diaphoresis, dyspnea, and anxiety, making myocardial infarction due to troponin levels the best answer.

❌ Why bleeding due to aPTT level is not the best answer

❌ The client’s aPTT is 32 seconds, which is within the expected reference range of 30 to 40 seconds.

❌ A normal aPTT does not show excessive anticoagulation or impaired clotting at the time of assessment.

❌ Although thrombolytic therapy can increase bleeding risk after it is started, the question asks based on the provided findings, and the listed aPTT does not support bleeding risk.

❌ If the aPTT were prolonged, the nurse would be more concerned about bleeding, especially in a client receiving anticoagulants.

❌ The strongest abnormal trend in the data is the rising troponin, not the aPTT.

❌ Why thrombosis due to platelets is not the best answer

❌ The client’s platelet count is 350,000/mm³, which is within the expected range of 150,000 to 400,000/mm³.

❌ A normal platelet count does not indicate thrombocytosis or abnormal clotting risk from platelets.

❌ Platelets can be involved in coronary clot formation, but this laboratory value does not show an abnormal platelet problem.

❌ The client’s symptoms are more directly supported by myocardial injury shown through rising troponin levels.

❌ For this question, the evidence points to myocardial infarction related to cardiac biomarker elevation, not thrombosis due to platelet count.

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Answer 3

Correct Answers

Shortness of breath with exertion [ Indication of potential improvement ]
Lung sounds clear [ Indication of potential improvement ]
WBC count 11,800/mm³ [ Unrelated to diagnosis ]
Weight 113 kg (249 lb) [ Indication of potential worsening condition ]
Temperature 38.5°C (101.3°F) [ Unrelated to diagnosis ]
Creatinine 1.8 mg/dL [ Indication of potential worsening condition ]

Rationale :

🫁 Shortness of breath with exertion — Indication of potential improvement

🫁 The client initially had shortness of breath at rest, which is a more severe sign of fluid overload and poor oxygenation in heart failure.

🫁 After treatment, shortness of breath only with exertion suggests the client is tolerating rest better and may have improved pulmonary congestion.

🫁 In heart failure, improvement is seen when breathing becomes easier, oxygen demand decreases, and the client can rest without distress.

🫁 This does not mean the client is fully stable, but it is better than dyspnea occurring while at rest.

🫁 The nurse should continue monitoring respiratory rate, oxygen saturation, lung sounds, activity tolerance, and response to furosemide.

✅ Lung sounds clear — Indication of potential improvement

✅ The client initially had crackles at both lung bases, which indicated fluid accumulation in the lungs.

✅ Clear lung sounds suggest that excess fluid is decreasing and pulmonary congestion is improving.

✅ IV furosemide promotes diuresis, which helps remove excess fluid and reduces pressure in the pulmonary circulation.

✅ Improved lung sounds are an important sign that the heart failure treatment is working.

✅ The nurse should continue monitoring for recurrence of crackles, dyspnea, oxygen changes, and fluid overload.

❌ WBC count 11,800/mm³ — Unrelated to diagnosis

❌ A WBC count of 11,800/mm³ is elevated and suggests possible infection or inflammation.

❌ This finding is not a direct sign of heart failure improvement or worsening.

❌ The client has a history of recurrent UTIs and reported dysuria on admission, so the elevated WBC may be related to a urinary infection.

❌ While infection can worsen overall condition, the lab itself points more toward an infectious process than fluid overload.

❌ The nurse should report and follow up with urine testing, temperature trends, and signs of sepsis.

⚖️ Weight 113 kg (249 lb) — Indication of potential worsening condition

⚖️ The client’s weight increased from 111 kg to 113 kg, which is a gain of about 2 kg or 4 lb in 24 hr.

⚖️ In heart failure, rapid weight gain usually indicates fluid retention.

⚖️ This is concerning because the client is receiving IV furosemide, so weight should ideally decrease as excess fluid is removed.

⚖️ Continued weight gain can mean the diuretic response is inadequate or fluid overload is worsening.

⚖️ The nurse should assess intake and output, edema, lung sounds, oxygenation, urine output, and notify the provider if fluid retention continues.

❌ Temperature 38.5°C (101.3°F) — Unrelated to diagnosis

❌ Fever is not an expected finding of heart failure itself.

❌ A temperature of 38.5°C suggests possible infection, especially because the client has dysuria and a history of recurrent UTIs.

❌ Infection can increase metabolic demand and place extra strain on the heart, but the fever points to another problem rather than heart failure directly.

❌ The nurse should monitor for chills, worsening urinary symptoms, altered mental status, and abnormal cultures.

❌ This finding needs follow-up because infection can trigger worsening heart failure if untreated.

🧪 Creatinine 1.8 mg/dL — Indication of potential worsening condition

🧪 Creatinine increased from 0.9 mg/dL to 1.8 mg/dL, showing worsening kidney function.

🧪 This is concerning because heart failure can reduce renal perfusion, and aggressive diuresis can also contribute to dehydration or kidney injury.

🧪 Furosemide removes fluid, but excessive fluid loss or poor cardiac output can decrease blood flow to the kidneys.

🧪 Worsening creatinine may indicate the client is not tolerating treatment well or that perfusion is declining.

🧪 The nurse should monitor urine output, electrolytes, blood pressure, daily weight, and notify the provider.

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Answer 4

Correct Answers:

“I have lunch with my friends once a week."

Rationale :

💛 Maintaining social connections is a strong indicator of effective coping when dealing with a partner’s terminal illness.

💛 Having lunch with friends shows the client is seeking emotional support, which helps reduce stress, grief, and isolation.

💛 Healthy coping includes balancing caregiving responsibilities with personal well-being and social interaction.

💛 This behavior promotes resilience, emotional expression, and prevents caregiver burnout.

💛 It reflects the ability to adapt and maintain supportive relationships during a stressful life situation.

❌ “I cook my partner’s favorite foods.”

This reflects caregiving behavior and concern for the partner’s comfort. However, it does not directly demonstrate the client’s own coping or emotional support system.

❌ “I am unable to fall asleep right away.”

Difficulty sleeping is a common response to stress. It indicates emotional strain rather than effective coping.

❌ “I make a list of all the things I need to do.”

Organizing tasks can help with daily functioning. However, it focuses on responsibilities rather than emotional coping or support.

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Answer 5

Correct Answers

Blank 1 Correct Option: wound infection
Blank 2 Correct Option: blood glucose level

Rationale :

🦠 Why wound infection is correct

🦠 The client is postoperative after a total knee arthroplasty, which already places them at risk for surgical site infection.

🦠 The client has type 2 diabetes mellitus, a major risk factor for impaired healing and infection.

🦠 Poor glycemic control is evident from the Hemoglobin A1C of 9.5%, indicating long-term uncontrolled diabetes.

🦠 Postoperatively, infection risk increases due to tissue trauma, incision, and possible reduced immune response.

🦠 Combining surgery + diabetes + poor control significantly increases the likelihood of wound infection compared to other complications.

🩸 Why blood glucose level is correct

🩸 The client’s glucose increased from 190 mg/dL pre-op to 280 mg/dL post-op, which is critically elevated.

🩸 Hyperglycemia impairs immune function, particularly neutrophil activity, reducing the body’s ability to fight infection.

🩸 Elevated glucose also delays collagen synthesis and wound healing, increasing the chance of surgical site breakdown.

🩸 Stress from surgery can worsen hyperglycemia, especially in clients with poorly controlled diabetes.

🩸 This makes the blood glucose level the strongest evidence supporting infection risk.

❌ Why stroke due to blood pressure is not the best answer

❌ The client’s blood pressure is 136/85 mm Hg, which is only mildly elevated and not in a critical range.

❌ Stroke risk is more associated with severe or uncontrolled hypertension, not this moderate postoperative value.

❌ There are no neurologic symptoms such as weakness, speech changes, or altered consciousness.

❌ While hypertension is a risk factor, it is not the most immediate concern in this scenario.

❌ The glucose abnormality presents a more urgent and direct complication risk.

❌ Why pneumonia due to oxygen saturation is not the best answer

❌ The client’s oxygen saturation is 98% on 2 L nasal cannula, which indicates adequate oxygenation.

❌ There are no findings such as crackles, fever, productive cough, or respiratory distress suggesting pneumonia.

❌ Although postoperative clients are at risk for pneumonia, current data does not support this complication.

❌ Respiratory rate is slightly elevated but not accompanied by other signs of infection.

❌ Compared to hyperglycemia, there is no strong evidence pointing toward pneumonia at this time.

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Answer 6

Correct Answers:

Use text or pictures to communicate needs postoperatively.

Rationale :

👅 A partial glossectomy involves removal of part of the tongue, which can temporarily or permanently affect speech and swallowing.

👅 Using text or pictures helps the client communicate pain, toileting needs, airway discomfort, suction needs, and emotional concerns after surgery.

👅 Communication support is important because the client may have swelling, dressings, difficulty speaking, or airway-related equipment postoperatively.

👅 The nurse should prepare communication tools before surgery so the client can express needs immediately after the procedure.

👅 This promotes safety, reduces anxiety, and supports client-centered postoperative care.

❌ Increase intake of dense, high-fiber foods.

Dense foods can be difficult to chew and swallow after tongue surgery. The client usually needs soft, moist, high-calorie, high-protein foods as prescribed.

❌ Inspect the mouth once each week for sores.

The mouth should be inspected more frequently after oral surgery. Weekly assessment is not enough because bleeding, infection, swelling, or wound breakdown can develop quickly.

❌ Rinse with an alcohol-based mouthwash instead of brushing.

Alcohol-based mouthwash can irritate oral tissues and delay healing. Oral care should be gentle and follow provider instructions.

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Answer 7

Correct Answers:

Document the donation number of the unit of blood on the client's electronic medical record.

Rationale :

🩸 The nurse must document the donation number of the blood product to ensure traceability and transfusion safety.

🩸 Blood products require strict verification because transfusion reactions can be life-threatening.

🩸 Documentation should include product type, donation number, blood compatibility verification, start and stop times, vital signs, and client response.

🩸 The nurse should also verify the blood product with another qualified staff member according to facility policy before starting the transfusion.

🩸 Accurate documentation supports legal, clinical, and blood bank tracking requirements.

❌ Check the first set of vital signs 30 min after the blood infusion is started.

Vital signs should be checked before starting the transfusion and then shortly after initiation, often within the first 15 minutes. Most severe transfusion reactions occur early.

❌ Infuse the unit of blood to the client over 6 hr.

A unit of blood should generally be completed within 4 hours to reduce bacterial growth risk. Six hours is too long.

❌ Prime the blood administration IV tubing with lactated Ringer’s.

Blood tubing should be primed with 0.9% sodium chloride. Lactated Ringer’s contains calcium, which can promote clotting when mixed with blood.

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Answer 8

Correct Answers:

Flush the toilet with the lid closed three times after use.

Rationale :

☢️ Radioactive isotope therapy can cause body fluids, including urine, to contain radioactive material for a period of time after treatment.

☢️ Flushing the toilet with the lid closed three times helps reduce radioactive contamination and prevents splashing.

☢️ The client should also wash hands well after toileting and follow radiation safety instructions closely.

☢️ These precautions protect family members and caregivers from unnecessary radiation exposure.

☢️ The teaching focuses on limiting contamination from body fluids while the isotope is being eliminated.

❌ Use cloth handkerchiefs instead of disposable tissues.

Disposable tissues are preferred because secretions can contain radioactive material. Used tissues should be discarded as instructed instead of reused.

❌ Use absorbent briefs for incontinence as needed.

Absorbent briefs can collect radioactive urine and increase contamination risk. If incontinence is present, special handling instructions are needed.

❌ Remain at least 1 foot away from young children during treatment.

One foot is not enough distance from young children during radioactive therapy precautions. Greater distance and limited contact are usually required.

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Answer 9

Correct Answers:

"l break out in a rash when I eat strawberries."

Rationale :

🍓 A reaction to strawberries can indicate a possible latex-fruit sensitivity pattern.

🍓 Some clients with latex allergy also react to certain fruits due to cross-reacting proteins.

🍓 Rash after eating strawberries suggests an allergic-type response that should be assessed further before surgery.

🍓 The nurse should notify the surgical team and ensure latex-free supplies are available if latex sensitivity is suspected.

🍓 Identifying this risk helps prevent intraoperative allergic reactions.

❌ “I often have diarrhea after eating scrambled eggs.”

Egg intolerance or allergy is not a classic indicator of latex sensitivity. It may be relevant for other allergy screening but not specifically latex.

❌ “I have trouble urinating if I eat acidic foods.”

Urinary difficulty after acidic foods is not an allergic response. It does not suggest latex sensitivity.

❌ “I sometimes start to wheeze when I eat peanuts.”

Peanut allergy can cause serious respiratory reactions. However, it is not the best indicator of possible latex allergy from the choices.

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Answer 10

Correct Answers:

"l can arrange for a social worker to talk with you before you leave."

Rationale :

🤝 A social worker can help the client access financial assistance, medication programs, insurance resources, and community support.

🤝 Medication affordability is a discharge safety issue because inability to obtain prescriptions can lead to nonadherence and worsening illness.

🤝 The nurse should not simply tell the client to solve the issue alone because the care team can help connect them with resources.

🤝 Social work involvement supports continuity of care after discharge.

🤝 This response addresses the client’s concern directly and promotes safe medication access.

❌ “Contact your pharmacy to inquire about a different medication.”

The pharmacy cannot independently change the prescribed medication. Medication changes require provider approval.

❌ “You should ask your provider to prescribe a cheaper medication.”

The provider may help, but this response places the burden on the client. The nurse should initiate appropriate support before discharge.

❌ “I can contact the occupational therapist to schedule a home visit.”

Occupational therapy helps with activities of daily living and home safety. It does not primarily address medication affordability.

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Findings 24 hr later	Unrelated to diagnosis	Indication of potential improvement	Indication of potential worsening condition
Shortness of breath with exertion
Lung sounds clear
WBC count 11,800/mm³
Weight 113 kg (249 lb)
Temperature 38.5°C (101.3°F)
Creatinine 1.8 mg/dL

QLexNursing

1 :
A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

2 :
A nurse is caring for a client who has angina.

Correct Answers

3 :
A nurse is caring for a client who is experiencing an exacerbation of heart failure.

Correct Answers

4 :
A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

5 :
A nurse is caring for a client who is postoperative following a total knee arthroplasty.

Correct Answers

🦠 Why wound infection is correct

🩸 Why blood glucose level is correct

❌ Why stroke due to blood pressure is not the best answer

❌ Why pneumonia due to oxygen saturation is not the best answer

6 :
A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

8 :
A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

9 :
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?

10 :
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?

QLexNursing

1 : A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

2 : A nurse is caring for a client who has angina.

Correct Answers

3 : A nurse is caring for a client who is experiencing an exacerbation of heart failure.

Correct Answers

4 : A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

5 : A nurse is caring for a client who is postoperative following a total knee arthroplasty.

Correct Answers

🦠 Why wound infection is correct

🩸 Why blood glucose level is correct

❌ Why stroke due to blood pressure is not the best answer

❌ Why pneumonia due to oxygen saturation is not the best answer

6 : A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

8 : A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

9 : A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?

10 : A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?

1 :
A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

2 :
A nurse is caring for a client who has angina.

3 :
A nurse is caring for a client who is experiencing an exacerbation of heart failure.

4 :
A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

5 :
A nurse is caring for a client who is postoperative following a total knee arthroplasty.

6 :
A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

8 :
A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

9 :
A nurse is assessing a preoperative client for allergies. Which of the following client statements would the nurse identify as a risk for an allergy to latex?

10 :
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?