A client who had abdominal surgery reports feeling "a pop”. in his incisional area followed by severe pain when he turned in bed earlier in his shift; he now reports feeling "wet”. in his abdominal area under his gown and dressing. The nurse should:

Call for assistance and stay with client.

Remove dressing to assess wound.

Cover wound with sterile towels soaked in sterile saline.

Assess vital signs.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped”. or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B reason:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C reason:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D reason:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.

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Correct Answer is ["C","D"]

Explanation

Choice A reason:

This response is not appropriate because it does not acknowledge the patient's pain or offer any pain relief. It also sounds dismissive and unsympathetic to the patient's feelings. A better response would be to empathize with the patient and explain the benefits and risks of early mobilization in a respectful way.

Choice B reason:

This response is not appropriate because it does not address the patient's pain or provide any pain relief. It also sounds demanding and authoritarian, which may increase the patient's anxiety and resistance. A better response would be to collaborate with the patient and set realistic and individualized goals for mobility.

Choice C reason:

This response is appropriate because it acknowledges the patient's pain and offers a solution to reduce it. It also shows respect for the patient's autonomy and readiness by suggesting rather than ordering to get up. It also implies that the nurse will assist and support the patient during the activity.

Choice D reason:

This response is appropriate because it provides positive reinforcement and education to the patient. It explains how early mobilization can enhance wound healing and decrease pain by improving blood circulation, preventing complications, and restoring function.

Choice E reason:

This response is not appropriate because it sounds accusatory and judgmental. It may make the patient feel defensive or guilty for expressing their pain or reluctance. A better response would be to explore the patient's concerns and fears in a non-threatening way and provide reassurance and information as needed.

A. Placing a pillow under the dependent axilla. B. Flexing both knees at a 90-degree angle. C. Aligning the shoulders directly over each other. D. Elevating the dependent arm on an arm board.

Correct Answer is A

Explanation

Choice A reason:

Placing a pillow under the dependent axilla is a proper technique for lateral positioning because it helps to prevent brachial plexus injury by reducing the pressure on the neurovascular structures in the axilla. It also helps to maintain the alignment of the shoulder and prevent shoulder drop.

Choice B reason:

Flexing both knees at a 90-degree angle is not a proper technique for lateral positioning because it can cause excessive pressure on the knees and ankles, leading to nerve injury or skin breakdown. It can also impair venous return and increase the risk of deep vein thrombosis (DVT) Only the dependent leg should be flexed at the hip and knee, while the upper leg should be straight and supported by pillows between the legs.

Choice C reason:

Aligning the shoulders directly over each other is not a proper technique for lateral positioning because it can cause compression of the dependent shoulder and compromise the blood supply to the arm. It can also cause shoulder drop and brachial plexus injury. The lower shoulder should be pulled slightly forward and supported by a pad under the chest wall.

Choice D reason:

Elevating the dependent arm on an arm board is not a proper technique for lateral positioning because it can cause excessive abduction of the arm and stretch the brachial plexus. It can also interfere with surgical access to the thorax or kidney. Both arms should be supported on parallel arm boards with abduction less than 90 degrees.

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A client who had abdominal surgery reports feeling "a pop”. in his incisional area followed by severe pain when he turned in bed earlier in his shift; he now reports feeling "wet”. in his abdominal area under his gown and dressing. The nurse should:

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Naxlex Comprehensive Predictor Exams

A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

The nurse is assisting with positioning a client for surgery in the lateral position. Which action by the nurse demonstrates proper technique?

Correct Answer is A

Explanation

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