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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I should use a heating pad when my feet are cold.": Clients with diabetes mellitus may have reduced sensation due to peripheral neuropathy. Using a heating pad increases the risk of burns or injury due to the inability to perceive excessive heat.

B. "I should plan to remain barefoot while I am at home.": Walking barefoot increases the risk of foot injuries, which can lead to infections and complications such as diabetic ulcers. Clients should always wear well-fitting shoes, even at home, to protect their feet.

C. "I should apply lotion between my toes twice a day.": Moisturizing the feet is important to prevent dryness and cracking, but applying lotion between the toes can create excess moisture, increasing the risk of fungal infections.

D. "I should file the edges of my toenails after trimming them.": Filing the edges helps smooth sharp corners, reducing the risk of ingrown toenails and foot injuries, which can be difficult to heal in individuals with diabetes.

A. "I will take ibuprofen for mild pain." B. "I will weigh myself every other day." C. "I will keep an exercise diary." D. "I will expect swelling in my feet and ankles."

Correct Answer is C

Explanation

A. "I will take ibuprofen for mild pain": NSAIDs like ibuprofen can lead to sodium and fluid retention, which can exacerbate heart failure by increasing preload and worsening edema. They can also reduce the effectiveness of diuretics and ACE inhibitors, both of which are commonly used in heart failure management. Acetaminophen is generally preferred for pain relief as it does not contribute to fluid retention.

B. "I will weigh myself every other day": Daily weight monitoring is essential for detecting fluid retention early, as a sudden increase of 2–3 pounds in 24 hours or 5 pounds in a week can indicate worsening heart failure. Weighing every other day may delay the recognition of fluid overload, increasing the risk of complications such as pulmonary congestion and hospitalization.

C. "I will keep an exercise diary": Regularly tracking physical activity helps assess functional status and detect any decline in exercise tolerance, which could indicate worsening heart failure. An exercise diary allows the healthcare team to adjust activity levels appropriately, ensuring that the client remains active without overexertion. This approach also promotes adherence to a safe and structured exercise regimen, improving overall cardiovascular health.

D. "I will expect swelling in my feet and ankles": While mild peripheral edema can occur, it should never be considered normal in heart failure management. Swelling in the lower extremities suggests worsening fluid retention and should be promptly reported to the healthcare provider. Early intervention, such as medication adjustments or dietary modifications, can help prevent further decompensation and reduce the risk of hospitalization.

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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?

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