A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

Cover the wound with sterile, saline-soaked gauze.

Raise the head of the bed to a 45° angle.

Hold gentle, direct pressure on the protruding organ

Place the client's knees in an extended position.

Answer and Explanation

The Correct Answer is A

Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.

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Correct Answer is D

Explanation

The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.

A. Refer the client to a support group for clients who have eating disorders. B. Instruct the client about effective coping strategies C. Observe the client during and after meals. D. Suggest that the client assist with meal planning

Correct Answer is C

Explanation

The correct answer is C. Observe the client during and after meals. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The nurse should monitor the client for signs of purging, such as frequent trips to the bathroom, and provide support and supervision during and after meals to prevent this behavior . This is a priority intervention that addresses the client's physical health and safety.

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A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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