A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?
Visualize the abdominal incision.
Obtain sterile towels soaked in saline.
Assure the client that such feelings occur with wound infections.
Notify the healthcare provider
The Correct Answer is A
A. Visualize the abdominal incision: The client’s description suggests a possible wound dehiscence or evisceration, which is a surgical emergency. The nurse’s immediate priority is to assess the site directly to confirm the condition before implementing further steps. Visual confirmation guides the urgency and next actions in management.
B. Obtain sterile towels soaked in saline: This is an essential intervention if evisceration is confirmed, as moist sterile dressings protect exposed abdominal organs from drying and infection. However, this should come only after the nurse visually inspects the wound to determine if evisceration has occurred.
C. Assure the client that such feelings occur with wound infections: This response dismisses the client's serious concern and does not address the potential for a severe surgical complication. While discomfort is expected with a wound infection, the feeling of "insides spilling out" is not a normal occurrence and requires immediate investigation.
D. Notify the healthcare provider: While the provider must be informed if evisceration or dehiscence is present, immediate nursing assessment comes first. The nurse must evaluate the situation and initiate necessary interventions like covering exposed organs before contacting the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
Calculate the volume to administer:
Volume (mL) = Desired dose (mg) / Concentration (mg/mL)
= 10 mg / 50 mg/mL
= 0.2 mL
Correct Answer is B
Explanation
A. Chicken, rice, and wheat products: While these foods can be part of a balanced diet, they are relatively low in dietary fiber. A diet rich in fiber is associated with a decreased risk of colorectal cancer by promoting regular bowel movements and reducing exposure of the colon lining to carcinogens.
B. Oatmeal, raisins, and fruit with skin: These foods are high in dietary fiber, which supports gastrointestinal health by increasing stool bulk and reducing intestinal transit time. High-fiber diets are linked to a lower risk of colon and rectal cancers, making this group of foods the most appropriate recommendation for at-risk clients.
C. Potatoes, low-fat breads, and applesauce: Although low in fat, these foods lack the dietary fiber content found in whole fruits and grains. Applesauce, in particular, is often low in fiber compared to whole fruits. This group does not offer the same protective benefit against colorectal cancer as high-fiber options.
D. Lean beef, salads, and baked potatoes: While salads provide fiber, regular consumption of red meat like beef has been associated with an increased risk of colorectal cancer. This group offers some benefits but is not the best overall recommendation for clients with a family history of colorectal cancers.
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