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?

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

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

Attempt to reinsert the protruding viscera.

Place the client in left lateral recumbent position.

Answer and Explanation

The Correct Answer is A

A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.

B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.

C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.

D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Increased body hair: Adrenal insufficiency leads to decreased androgen production, which may cause hair thinning rather than increased body hair. Hypertrichosis (excessive hair growth) is not a typical finding in adrenal insufficiency.

B. Decreased blood urea nitrogen level: Adrenal insufficiency is often associated with dehydration due to aldosterone deficiency, leading to reduced sodium retention and increased fluid loss. This can result in elevated blood urea nitrogen (BUN) levels rather than a decrease.

C. Hyperpigmentation of the skin: Increased melanocyte-stimulating hormone (MSH) activity, triggered by elevated adrenocorticotropic hormone (ACTH) levels, causes darkening of the skin, especially in sun-exposed areas, skin folds, and mucous membranes. This is a hallmark feature of primary adrenal insufficiency (Addison’s disease).

D. Hypocalcemia: Adrenal insufficiency is more commonly associated with hypercalcemia rather than hypocalcemia. Decreased cortisol levels can lead to reduced renal calcium excretion, contributing to elevated serum calcium levels.

A. "I will hold my cellphone on the opposite side of the pacemaker." B. "I can resume physical activity within 2 weeks." C. "I need to cover my pacemaker with a dressing when I shower." D. "I should avoid using a microwave oven."

Correct Answer is A

Explanation

A. "I will hold my cellphone on the opposite side of the pacemaker.": Cellphones emit electromagnetic signals that can interfere with pacemaker function if held directly over the device. Keeping the phone on the opposite side minimizes the risk of interference and ensures proper pacemaker function.

B. "I can resume physical activity within 2 weeks.": Strenuous physical activity should be avoided for about 4-6 weeks to allow proper healing of the pacemaker site. Early resumption of activity can lead to lead dislodgement or complications.

C. "I need to cover my pacemaker with a dressing when I shower.": After the initial post-procedure period, there is no need to keep the pacemaker site covered while showering. The incision should be kept dry until it fully heals, but a permanent dressing is unnecessary.

D. "I should avoid using a microwave oven.": Modern pacemakers are shielded against microwave interference, making it safe to use a microwave. This is a common misconception, as older pacemakers were more susceptible to electrical interference.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is planning care for a client who is experiencing seizures secondary to meningitis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A nurse is caring for a client who is postoperative following a total knee arthroplasty. Complete the following sentence by using the lists of options. The client is at the highest risk for ...... as evidenced by the client's ......

A nurse is assessing a client who is taking lisinopril. Which of the following findings should the nurse document in the client's medical record as an adverse effect?

A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control?

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy?

A nurse is reviewing the results of electrocardiography monitoring for a client who has atrial fibrillation. Which of the following findings should the nurse expect?