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","B"]

Explanation

Wound appearance: The client's wound is consistent in size (3 cm x 4 cm) but the purulent drainage may indicate ongoing infection. However, the key aspect is that the client has a scheduled appointment with a wound care specialist, which suggests that there is a plan in place for managing the wound, indicating that the situation is being monitored and potentially improving with treatment.
Blood glucose: The blood glucose level decreased from 250 mg/dL two weeks ago to 140 mg/dL today. While still elevated, this reduction indicates better glycemic control, which is essential for overall health and particularly important in the context of healing and managing diabetes.

WBC: The WBC count increased from 9,500/mm³ to 11,200/mm³. This increase could indicate an ongoing infection or inflammatory process, suggesting that the client's condition is not improving in this regard.
Urinary frequency: The information provided does not detail any changes in urinary frequency, and given the initial presentation of increased thirst and urination, ongoing monitoring is essential. Without additional context, this does not indicate improvement.
Temperature: The temperature increased from 38.3°C (100.9°F) to 39.0°C (102.2°F), indicating a worsening state that may suggest infection or systemic response rather than improvement.
Blood pressure: The blood pressure dropped from 98/74 mm Hg to 90/68 mm Hg, which is concerning and indicates potential hypotension, possibly due to infection or other factors affecting the client’s status.
Heart rate: The heart rate increased from 104/min to 106/min, suggesting that the client may be experiencing stress, pain, or infection, indicating that their condition may not be improving.

A. Hospice care services B. Long-term care facility C. Rehabilitation center D. Visiting nurse services

Correct Answer is D

Explanation

A. Hospice care services: Hospice care is designed for clients with terminal illnesses who require end-of-life care. Crohn’s disease and an ileostomy do not indicate a terminal condition, making hospice services inappropriate for this client.

B. Long-term care facility: Long-term care facilities are for clients who need continuous medical or personal care and are unable to live independently. Most clients with an ileostomy can manage their care at home with proper education and support, making this resource unnecessary.

C. Rehabilitation center: Rehabilitation centers are primarily for clients recovering from major injuries, strokes, or surgeries that impair mobility or function. While an ileostomy requires adjustment, it does not typically necessitate inpatient rehabilitation.

D. Visiting nurse services: Home health nurses provide essential support for clients with a new ileostomy by assisting with ostomy care, monitoring for complications, and reinforcing self-care education. This service helps facilitate a smoother transition to independent ostomy management.

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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?

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