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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["C","D","E","G"]

Explanation

Pain level: Chest pain rated at 7/10 with radiation to the left arm, along with diaphoresis and nausea, indicates a potential acute coronary syndrome, likely a myocardial infarction. Immediate intervention is necessary to relieve pain and address the underlying cause, as this could prevent further complications and potential cardiac damage.
Electrocardiogram findings: ST-segment elevation and T wave changes suggest an ST-elevation myocardial infarction (STEMI), which requires urgent medical attention. Prompt identification and activation of treatment protocols, such as percutaneous coronary intervention (PCI) or thrombolytic therapy, are critical to restore blood flow and minimize myocardial damage.
Troponin T level: An elevated troponin T level (0.40 ng/mL, with a normal range <0.1 ng/mL) indicates myocardial injury, supporting the diagnosis of an acute myocardial infarction. Immediate management is essential to mitigate further cardiac injury and ensure appropriate treatment is initiated based on the severity of the elevation.
Blood pressure: While the blood pressure reading of 164/80 mm Hg indicates hypertension, it is not critically high and does not require immediate intervention like the other findings. However, elevated blood pressure in the context of a myocardial infarction can increase myocardial oxygen demand, leading to further complications, thus it should be monitored closely.

Blood glucose level: The blood glucose level of 103 mg/dL is within normal limits (74-106 mg/dL) and does not indicate an immediate concern. Although monitoring blood glucose is essential in clients with diabetes, it is not a priority in the context of acute coronary syndrome.
Bowel sounds: The presence of bowel sounds indicates gastrointestinal function and does not require immediate follow-up in this context. While it’s important to assess overall health, bowel sounds are not a priority when addressing acute cardiac symptoms.
Lung sounds: Clear lung sounds indicate that there is no pulmonary congestion or other respiratory complications at this time. While lung assessment is essential for overall patient evaluation, clear lung sounds do not require immediate follow-up in this acute setting.

A. Constipation B. Peripheral neuropathy C. Mouth ulcers D. Decreased tear production

Correct Answer is C

Explanation

A. Constipation: Radiation therapy to the neck does not typically affect the gastrointestinal system directly. Constipation is more commonly associated with opioid pain management or radiation targeting the abdominal or pelvic region rather than the head and neck area.

B. Peripheral neuropathy: Nerve damage leading to peripheral neuropathy is more often linked to chemotherapy, particularly agents like vincristine or cisplatin, rather than radiation therapy. Radiation to the neck primarily affects tissues in the irradiated field, such as the oral mucosa.

C. Mouth ulcers: Radiation to the neck frequently causes mucositis, leading to painful mouth ulcers due to the direct impact on rapidly dividing mucosal cells. Clients may experience pain, difficulty swallowing, and increased risk of infection as a result of mucosal breakdown.

D. Decreased tear production: Radiation therapy to the neck is unlikely to directly affect the lacrimal glands. While radiation near the eyes can cause dry eyes, treatment focused on the neck primarily impacts the oral mucosa, salivary glands, and throat rather than tear production.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy?

Correct Answer is C

Explanation

A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure?

A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 mL in the past 12 hr. Which of the following medications should the nurse expect to administer to the client?

A nurse is caring for a client who has developed a paralytic ileus related to acute pancreatitis and reports pain as 8 on a scale of 0 to 10. The client has prescriptions for multiple PRN pain medications. Which of the following medications should the nurse administer?

A nurse is preparing to administer a medication for a client through a nontunneled percutaneous central catheter. Which of the following actions should the nurse take?

A nurse is teaching a client who is newly diagnosed with type 2 diabetes mellitus about insulin therapy. Which of the following insulin combinations should the nurse instruct the client to mix?

A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?