A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Gently suction secretions from the wound bed using a 12-gauge sterile catheter.

Cover the area with saline-soaked sterile dressings.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.

Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.

Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.

Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.

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 B

Explanation

Choice A reason: Opioid analgesics do not typically increase coughing; they may actually suppress cough reflexes.

Choice B reason: Opioid analgesics are known to have a calming effect, which can help reduce anxiety in postoperative patients.

Choice C reason: Opioids can lead to decreased blood pressure, not an increase.

Choice D reason: Opioids typically decrease the respiratory rate, which is a potential side effect that needs to be monitored.

A. Determine the client's level of anxiety. B. Interrupt the compulsive behavior. C. Use negative reinforcement techniques to prevent the client from performing rituals. D. Encourage avoidance of situations that increase anxiety.

Correct Answer is A

Explanation

Choice A reason: Assessing the client's level of anxiety is crucial as it can inform the nurse about the severity of the OCD symptoms and guide further interventions.

Choice B reason: Interrupting compulsive behavior abruptly can cause significant distress to the client and is not recommended without proper behavioral therapy techniques.

Choice C reason: Negative reinforcement techniques are not typically used in OCD management as they can exacerbate anxiety and are not considered therapeutic.

Choice D reason: Encouraging avoidance of anxiety-increasing situations may reinforce OCD behaviors and is not a recommended approach. Exposure and response prevention, a type of cognitive-behavioral therapy, is often used instead.

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 is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

Correct Answer is B

Explanation

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

Which of these would the nurse implement as the priority action for the patient with newly diagnosed septic shock?

The nurse is reinforcing teaching provided to a patient with Raynaud's disease. Which measure should the nurse include to prevent an attack?

The nurse is assisting in the care of a preoperative patient. The patient states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

A primary mechanism used by people with personality disorders is:

The 3 main types of Phobias as identified by DSM-5 include: (select all that apply)