a client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention when changing the clients dres
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

2. While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?

Correct answer: A

Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.

3. The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.

4. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

5. A healthcare professional is preparing to perform a sterile dressing change for a client. Which of the following actions should the healthcare professional plan to take?

Correct answer: B

Rationale: Setting up the sterile field at waist level is crucial to maintaining its sterility during a dressing change. Choice A is incorrect because sterile gloves should be worn after opening sterile dressing supplies to prevent contamination. Choice C is incorrect as the entire border of the sterile field should be considered contaminated to maintain sterility. Choice D is incorrect because the cap of a sterile solution should never be placed inside the sterile field to prevent contamination.

Similar Questions

A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP), and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

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