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 B
Explanation
Choice A rationale:
Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice B rationale:
Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.
Choice C rationale:
Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice D rationale:
Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Correct Answer is A
Explanation
Choice A rationale:
Superficial wounds heal faster when kept moist.
Choice B rationale:
Wet-to-dry dressings are not typically used for superficial wounds as they can cause trauma to the wound bed during removal.
Choice C rationale:
Occlusion can help maintain a moist environment, but it’s not the only factor in wound healing.
Choice D rationale:
Debridement is the removal of dead or infected tissue from a wound, which can promote healing, but it’s not the only factor.
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