A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?

Teaching a client to use a cane focuses on improving balance, stability, and safety during ambulation, especially when unilateral weakness is present. A cane should be used on the stronger side of the body to provide optimal support for the weaker lower extremity. Proper sequencing of cane and leg movement helps redistribute weight and reduce fall risk. Correct technique is essential for clients recovering from neurologic conditions such as stroke.

Rationale:
A. Positioning the cane 30.5 cm (12 in) to the side of the body is incorrect because the cane should be held close to the body for stability. Holding it too far away increases the risk of imbalance and reduces effective weight-bearing support. Proper placement is directly adjacent to the stronger leg.

B. Placing the cane on the right side is correct because the cane should be used on the unaffected or stronger side when the client has left-sided weakness. This allows the right side to support body weight while the left, weaker side advances safely. This technique improves balance and reduces fall risk in clients with conditions such as Stroke.

C. Advancing the cane 40.64 cm (16 in) with each step is incorrect because the cane should be moved only a short distance forward, typically about 15–25 cm (6–10 in). Moving it too far ahead reduces stability and increases the risk of loss of balance. Controlled, small movements are essential for safe ambulation.

D. Moving the right foot forward first is incorrect because the sequence should involve moving the cane and the weaker (left) leg first, followed by the stronger leg. Advancing the strong leg first disrupts balance and does not provide proper support for the affected side. Correct sequencing ensures safety and coordination during walking.

Wound evisceration is a rare but catastrophic surgical emergency characterized by the total separation of all layers of a surgical wound (dehiscence) with the protrusion of internal visceral organs through the incision. It occurs most frequently 3 to 11 days postoperatively and is associated with risk factors that increase intra-abdominal pressure, such as coughing, straining, or vomiting. Evisceration poses an immediate threat to the blood supply of the protruded organs, creating a high risk for tissue ischemia, necrosis, and overwhelming systemic peritonitis. Nursing interventions must focus on minimizing tension on the abdominal wall and protecting the exposed viscera until emergency surgical repair can be performed.

Rationale:

A. Positioning the client in a semi-Fowler's position is an incorrect choice. While a slight elevation of the head can sometimes be used in general respiratory care, a standard semi-Fowler's position can cause the torso to stretch or bend in a way that increases intra-abdominal pressure and allows gravity to force more of the internal organs out through the abdominal wall incision.

B. Covering the wound with a transparent dressing is an incorrect and contraindicated choice. Transparent film dressings do not provide adequate protection or moisture for exposed visceral organs. Eviscerated organs must be kept continuously moist; a transparent film dressing would trap air and cause the exposed bowel to dry out rapidly, leading to tissue friction, ischemia, and necrosis.

C. Instructing the client to lie supine with his knees flexed is the correct action the nurse should take. Placing the client in a low-Fowler's or supine position with the knees bent reduces tension on the abdominal muscles, decreases intra-abdominal pressure, and prevents further protrusion of the internal organs. Alongside this positioning, the immediate nursing priority is to cover the exposed organs with sterile dressings soaked in warm, sterile normal saline to maintain tissue perfusion and moisture, while simultaneously preparing the client for an emergency return to the operating room.

D. Covering the wound with a dry sterile dressing is an incorrect and highly dangerous act. Placing a dry dressing directly onto exposed internal organs causes the visceral tissue to adhere to the gauze fibers. When the dressing is eventually removed or shifted, it will cause severe tissue tearing, capillary damage, and significantly increase the risk of infection and necrosis. All dressings applied to an evisceration must be thoroughly saturated with sterile saline.