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 A

Explanation

A. Stop the infusion: Acute hemolytic reactions can occur within minutes of starting a transfusion and are life-threatening. Symptoms such as chills, lower back pain, and nausea indicate a potential reaction, requiring immediate discontinuation of the transfusion to prevent further hemolysis and organ damage.

B. Collect a urine sample: A urine sample helps detect hemoglobinuria, a sign of red blood cell destruction, but it is not the priority. The infusion must be stopped first to prevent further complications before obtaining a urine sample for analysis.

C. Check the client's vital signs: Monitoring vital signs is essential, but the priority is stopping the transfusion to halt the reaction. Vital signs should be checked after discontinuing the infusion to assess the severity of the reaction and guide further interventions.

D. Administer oxygen to the client: Oxygen may be needed if respiratory distress occurs, but stopping the transfusion is the first step to prevent continued exposure to the incompatible blood product. Oxygen therapy should be implemented based on the client's condition after discontinuing the infusion.

A. Restrict fluid intake. B. Place the client on a low sodium diet. C. Administer an iron supplement. D. Refer for a nutritional consult.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Anticipated:
• Administer an iron supplement.
• Refer for a nutritional consult.

Nonessential:
• Place the client on a low sodium diet.

Contraindicated:
• Restrict fluid intake.

Rationale:

• Administer an iron supplement: The client has iron deficiency anemia, indicated by low hemoglobin, hematocrit, RBC count, and ferritin levels. Iron supplementation is essential for replenishing iron stores and improving oxygen-carrying capacity.

• Refer for a nutritional consult: The client follows a vegan diet, which increases the risk of iron and vitamin B12 deficiencies. A nutritionist can provide dietary guidance to improve iron and vitamin intake through plant-based sources or supplementation.

• Place the client on a low sodium diet: Sodium restriction is typically necessary for conditions like hypertension, heart failure, or renal disease. There is no indication that

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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

Naxlex Comprehensive Predictor Exams

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a client. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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