A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).
Place the client in a low Fowler's position with the knees bent.
Cover the client's wound with a sterile saline-soaked dressing.
Notify the surgeon about the finding.
Prepare the client for transfer to surgery.
The Correct Answer is D
Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Verify that the client has adequate IV access.
Choice A rationale:
Administering vasopressin to the client might be necessary to manage the hemorrhage, but before any medication administration, it is crucial to ensure the client has adequate IV access. Vasopressin is a vasoconstrictor and can help control bleeding from esophageal varices, but its effectiveness relies on IV access to deliver the medication promptly.
Choice B rationale:
Requesting blood from the blood bank is essential for a client experiencing significant bleeding. However, the priority action is to verify IV access to administer any necessary blood products.
Choice C rationale:
This is the correct choice. Before initiating any interventions, ensuring the client has appropriate IV access is a priority. Adequate IV access is necessary to administer fluids, medications, or blood products promptly and effectively stabilize the client's blood pressure.
Choice D rationale:
Inserting an indwelling urinary catheter is not the priority action in this situation. While monitoring urine output is important, it should be secondary to addressing the client's hypotension and hemorrhage.
Correct Answer is B
Explanation
Choice A rationale:
The statement "If I can keep my hemoglobin A1C less than 6.5%, I will be cured of diabetes.”. is incorrect. While maintaining an A1C level below 6.5% is a recommended target for some individuals with diabetes, achieving this level does not cure diabetes. Diabetes is a chronic condition that requires ongoing management and lifestyle modifications.
Choice B rationale:
Checking blood sugar levels before exercising is an important aspect of managing type 1 diabetes. Exercise can affect blood glucose levels, and knowing the current level helps the client determine whether it is safe to engage in physical activity or if adjustments to insulin or carbohydrate intake are needed.
Choice C rationale:
Having regular eye checks every 2 years is essential for clients with diabetes, but it is not the best statement that indicates an understanding of health promotion activities for a new diagnosis of type 1 diabetes mellitus.
Choice D rationale:
Soaking feet daily in warm, soapy water is not a recommended practice for clients with diabetes. It can lead to skin dryness and increase the risk of infection. Instead, clients with diabetes should practice daily foot inspections and keep their feet moisturized to prevent complications related to peripheral neuropathy.
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