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 client has cellulitis on his left arm. What statement by the client indicates understanding of symptom management?

A. "I can use tight bandages on my arm."?
B. "I should not apply heat to my arm."?
C. "I can use a warm, moist towel on my arm."?
D. "I should use a cold, dry source on my arm."?

Correct answer: C

Rationale:

3. A client has a new arm cast. What is incorrect teaching by the nurse?

A. Use a sling to alleviate fatigue
B. Elevate the arm above the heart to reduce swelling
C. Report ‘hot spots’ felt under the cast
D. Sudden increase in drainage is expected

Correct answer: D

Rationale: Sudden increase in drainage is not expected and should be reported as it may indicate an infection or other complication.

4. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

A. Two-point gait
B. Three-point gait
C. Four-point gait
D. Unaffected gait

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.