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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Deep breathing and coughing exercises help clear the lungs and prevent atelectasis, a common postoperative respiratory complication.
Choice B reason: Incentive spirometry encourages patients to take deep breaths, which can help keep the lungs clear of mucus and prevent pneumonia.
Choice C reason: Leg exercises improve circulation and can help prevent blood clots, which can lead to pulmonary embolism, another serious respiratory complication.
Choice D reason: Early ambulation, or getting the patient moving as soon as possible after surgery, is crucial for preventing respiratory complications by promoting circulation and lung expansion.
Choice E reason: Hand squeezes are not directly related to preventing respiratory complications; they are more associated with preventing circulatory complications.
Correct Answer is C
Explanation
Choice A reason: Hypertension is not typically a direct complication of inhaled anesthetics.
Choice B reason: Urinary retention can occur postoperatively but is not specifically associated with inhaled anesthetics.
Choice C reason: Laryngospasm is a potential complication of inhaled anesthetics, which can occur due to irritation of the airway during anesthesia.
Choice D reason: Anxiety is not a complication of inhaled anesthetics; it is more likely to be associated with preoperative stress.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.