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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.

Choice B rationale:

Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.

Choice C rationale:

Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.

Choice D rationale:

Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.

A. "Bedside water pitchers should be covered after being filled.". B. "Dressings that get wet in the shower should be allowed to dry out.". C. "Used needles should be placed in the sharps container at the nurses' station.". D. "Drainage bottles should be emptied when they become full.".

Correct Answer is A

Explanation

Choice A rationale:

Covering bedside water pitchers after being filled helps reduce the risk of contamination and infection by preventing the entry of airborne pathogens or debris.

Choice B rationale:

Allowing dressings that get wet in the shower to dry out is not an effective infection control strategy. Wet dressings can become a breeding ground for bacteria, and it is important to change wet dressings promptly to minimize the risk of infection.

Choice C rationale:

Used needles should be immediately disposed of in sharps containers, not placed at the nurses' station. Placing used needles in the sharps container promptly helps prevent accidental needlestick injuries and potential transmission of infections.

Choice D rationale:

Drainage bottles should be emptied regularly to prevent overfilling, but they should not be allowed to become full. Regular emptying ensures proper functioning and reduces the risk of spillage or contamination in the client care area.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

Correct Answer is C

Explanation

A nurse educator is teaching a newly licensed nurse about strategies to reduce the risk of infection in the client care area. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

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