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.

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Correct Answer is D

Explanation

Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.

Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.

Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.

Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.

A. Surgical pause B. Time out C. Preoperative checklist D. Time in

Correct Answer is B

Explanation

Choice A reason: A surgical pause is not a commonly used term for this process.

Choice B reason: A time out is a standardized procedure used to verify the correct patient, procedure, and site before surgery begins.

Choice C reason: The preoperative checklist is a broader list of tasks completed before surgery, not the specific pause for verification.

Choice D reason: Time in is not a recognized term for this verification process in the surgical setting.

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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

When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

Correct Answer is D

Explanation

After positioning the patient on the surgical table and applying the safety strap, the surgical team pauses and verifies the patient and surgical information. What is this called?

Correct Answer is B

Explanation

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