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.

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Correct Answer is D

Explanation

A. Apply heating blanket as needed: Fever can worsen intracranial pressure (ICP) by increasing metabolic demand. Instead, cooling measures such as antipyretics or a cooling blanket should be used to maintain normothermia and prevent further ICP elevation.

B. Position the head of bed greater than 45°: Elevating the head of the bed slightly (30–45°) promotes venous drainage and reduces ICP. However, excessive elevation (>45°) may decrease cerebral perfusion pressure (CPP), leading to inadequate brain oxygenation.

C. Administer laxatives rectally: Rectal administration can stimulate the vagus nerve and increase ICP. Oral or IV stool softeners should be preferred to prevent straining, which can further elevate ICP.

D. Decrease stimulation in environment: Reducing noise, dimming lights, and minimizing disturbances help prevent spikes in ICP by decreasing sensory overload and stress. A calm environment supports cerebral oxygenation and prevents further elevation of ICP.

A. Chest tube with a drainage system B. NG tube with suction apparatus C. Chest physiotherapy vest D. Peak flow meter

Correct Answer is C

Explanation

A. Chest tube with a drainage system: A chest tube is typically used for pneumothorax or pleural effusion, not as a routine treatment for cystic fibrosis. While some clients with severe lung disease may require one in emergencies, it is not standard home care equipment.

B. NG tube with suction apparatus: While some clients with cystic fibrosis may require enteral feeding for nutritional support, an NG tube with suction is not a standard home intervention. Suctioning is generally needed for acute gastrointestinal obstruction rather than routine CF management.

C. Chest physiotherapy vest: This device helps loosen and mobilize thick mucus from the airways, improving airway clearance and reducing the risk of infections. It is a critical component of daily CF management and is commonly used in home settings.

D. Peak flow meter: A peak flow meter is more commonly used in asthma to monitor airway obstruction. In CF, lung function is better assessed with spirometry rather than peak expiratory flow, making this device less useful for routine home monitoring.

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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

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