A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?

Prepare the client for surgery.

Cover the protrusion with a dressing soaked in 0.9% sodium chloride.

Obtain the client's vital signs every 5 min until the provider arrives.

Raise the head of the bed to 20°.

Answer and Explanation

The Correct Answer is B

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

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Correct Answer is A

Explanation

A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.

B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.

C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.

D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.

A. Place pillows under the client's knees. B. Avoid use of anticoagulants. C. Discourage leg exercises while in bed. D. Apply compression stockings to the lower extremities.

Correct Answer is D

Explanation

A. Place pillows under the client's knees: Placing pillows under the knees can lead to venous stasis, increasing the risk of deep vein thrombosis (DVT). Prolonged knee flexion can also reduce circulation and contribute to joint stiffness. Instead, the client should be encouraged to keep their legs extended and change positions frequently to promote blood flow.

B. Avoid use of anticoagulants: Anticoagulants are commonly prescribed after surgery to prevent thromboembolic complications such as DVT and pulmonary embolism. Avoiding them may increase the client's risk of clot formation, especially if they have limited mobility. The decision to withhold anticoagulation should be based on specific contraindications rather than routine avoidance.

C. Discourage leg exercises while in bed: Leg exercises help prevent blood pooling in the lower extremities, reducing the risk of DVT. Discouraging movement can lead to complications such as impaired circulation, muscle stiffness, and clot formation. Encouraging active and passive range-of-motion exercises supports recovery and decreases the likelihood of postoperative complications.

D. Apply compression stockings to the lower extremities: Compression stockings help improve venous return and reduce the risk of clot formation by preventing blood from pooling in the lower extremities. They are particularly beneficial for clients with limited mobility after surgery. Using them in combination with early ambulation and anticoagulation therapy further decreases the risk of thromboembolic events.

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