Page 505 - Saunders Comprehensive Review For NCLEX-RN

shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of
86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all 4
quadrants are a normal occurrence in the immediate postoperative period.
Test-Taking Strategy: Note the strategic word, most. Focus on the subject, a
manifestation of an evolving complication in the immediate postoperative period.
Eliminate each of the incorrect options because they are comparable or alike and are
normal expected findings, especially given the time frame noted in the question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Foundations of Care: Perioperative Care
Health Problem: N/A
Priority Concepts: Clinical Judgment; Safety
Reference: Lewis et al. (2017), p. 331.

135. Answer: 1, 2, 3, 4

Rationale: Wound dehiscence is the separation of the wound edges. Wound
evisceration is protrusion of the internal organs through an incision. If wound
dehiscence or evisceration occurs, the nurse should call for help, stay with the client,
and ask another nurse to contact the surgeon and obtain needed supplies to care for
the client. The nurse places the client in a low-Fowler’s position, and the client is
kept quiet and instructed not to cough. Protruding organs are covered with a sterile
saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment
for evisceration is usually immediate wound closure under local or general
anesthesia. The nurse also documents the findings and actions taken.
Test-Taking Strategy: Focus on the subject, that the client is experiencing wound
evisceration. Visualizing this occurrence will assist you in determining that the client
would not be placed supine and that ice packs would not be placed on the incision.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Skills: Perioperative Care
Health Problem: Adult Health: Integumentary: Wounds
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), p. 283.

136. Answer: 1

Rationale: Routine screening tests include a complete blood count, serum
electrolyte analysis, coagulation studies, and a serum creatinine test. The complete
blood count includes the hemoglobin analysis. All of these values are within normal
range except for hemoglobin. If a client has a low hemoglobin level, the surgery
likely could be postponed by the surgeon.
Test-Taking Strategy: Focus on the subject, an abnormal laboratory result that
needs to be reported. Use knowledge of the normal reference intervals to assist in
answering correctly. The hemoglobin value is the only abnormal laboratory finding.

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