the nurse notes that a postoperative clients wound site is red and slightly swollen what is the most appropriate action
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Nursing Elites

HESI LPN

Adult Health 2 Final Exam

1. The nurse notes that a postoperative client's wound site is red and slightly swollen. What is the most appropriate action?

Correct answer: C

Rationale: The correct answer is to notify the surgeon. Redness and swelling at a wound site can indicate an infection, which may require medical intervention. Applying an ice pack (choice A) is not appropriate without further assessment. While documenting the findings and monitoring (choice B) is important, it should be accompanied by notifying the surgeon for further evaluation. Cleaning the wound with sterile saline (choice D) may not be sufficient if an infection is present, so immediate communication with the surgeon is crucial.

2. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?

Correct answer: B

Rationale: Reporting signs of bleeding is essential while on anticoagulant therapy to prevent complications.

3. The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?

Correct answer: C

Rationale: The correct answer is C because inspecting the stoma daily is crucial in identifying any early signs of complications or infections. Choice A is incorrect because changing the colostomy bag daily is not necessary unless there is a specific reason to do so. Choice B is incorrect as a low-fiber diet is not usually recommended for colostomy care. Choice D is incorrect because colostomy care should be performed regularly regardless of how the client feels.

4. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

5. The practical nurse is preparing to administer a prescription for cefazolin (Kefzol) 600 mg IM every six hours. The available vial is labeled, 'Cefazolin (Kefzol) 1 gram,' and the instructions for reconstitution state, 'For IM use add 2 ml sterile water for injection. Total volume after reconstitution = 2.5 ml.' When reconstituted, how many milligrams are in each milliliter of solution?

Correct answer: A

Rationale: After reconstitution, the concentration of cefazolin solution is calculated by dividing the total amount of drug (600 mg) by the total volume after reconstitution (2.5 mL). This gives 600 mg / 2.5 mL = 240 mg/mL. However, the question asks for the concentration in each milliliter of solution after reconstitution, so we need to consider the final volume of 2.5 mL. Therefore, 240 mg/mL * 2.5 mL = 600 mg, which means each milliliter contains 240 mg of cefazolin. Therefore, after reconstitution, there are 400 mg of cefazolin in each milliliter of solution. Choices B, C, and D are incorrect as they do not accurately reflect the concentration after reconstitution.

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