A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:
Ask someone to quickly get an abdominal binder.
Assist the patient in a supine position.
Seat the patient in a nearby chair.
Instruct the patient to pant to reduce abdominal tension.
The Correct Answer is B
Choice A rationale:
Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.
Choice B rationale:
Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.
Choice C rationale:
Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.
Choice D rationale:
Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
E.
Choice A rationale:
Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.
Choice B rationale:
Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.
Choice C rationale:
Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.
Choice D rationale:
Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.
Choice E rationale:
Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.
Correct Answer is A
Explanation
Choice A rationale:
Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.
Choice B rationale:
Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.
Choice C rationale:
Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.
Choice D rationale:
Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.
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