A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?
Turn the client onto her side.
Cover the wound with a moist sterile dressing
Apply an abdominal binder to the wound area.
Assure the client that this is an expected occurrence after surgery.
The Correct Answer is B
A. Turning the client onto her side could worsen the situation by increasing pressure on the abdominal area and potentially further damaging the eviscerated tissue. The priority is to manage the wound.
B. The correct intervention is to cover the wound with a moist sterile dressing to prevent further contamination and to protect the exposed organs. The nurse should also notify the surgical team immediately.
C. Applying an abdominal binder could put pressure on the wound and exacerbate the evisceration. It is not appropriate for the immediate care of an eviscerated wound.
D. Evisceration is a medical emergency and should never be considered an expected occurrence. The nurse should provide reassurance, but the primary focus should be on immediate wound care and notifying the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Elevating the head of the bed to 45° may increase the risk for pressure injuries, especially on the sacrum, due to increased pressure and friction from sliding down. The head of the bed should be kept as low as possible, typically at 30°, to reduce this risk.
B. Massaging bony prominences is not recommended for clients at risk for pressure injuries. Massage can cause tissue damage and exacerbate pressure injury formation. It is better to avoid massaging areas prone to injury and instead use appropriate repositioning techniques.
C. Providing a high-calorie diet is essential for clients at risk for pressure injuries. Adequate nutrition, including high-protein and high-calorie foods, helps support skin integrity, wound healing, and overall tissue repair, reducing the risk of developing pressure injuries.
D. Repositioning the client every 4 hours is insufficient for preventing pressure injuries. Clients at risk should be repositioned at least every 2 hours to relieve pressure on vulnerable areas and promote circulation to the skin.
Correct Answer is B
Explanation
A. Flushing the tube with sterile sodium chloride solution every 2 hours is not a standard recommendation. Typically, the tube is flushed with water to maintain patency, not specifically sterile sodium chloride, and not at such frequent intervals unless indicated by the facility's protocol.
B. Change the feeding bag every 24 hr is a recommended practice for continuous enteral feedings to prevent bacterial growth and infection.
C. Position the head of the client's bed at 15° is too low. The head of the bed should be elevated at least 30° to 45° to reduce the risk of aspiration and improve digestion during enteral feeding.
D. Check the gastric residual every 8 hr may not be sufficient. It is typically recommended to check the gastric residual more frequently, such as every 4 hours, to assess for proper gastric emptying and avoid complications like aspiration or feeding intolerance.
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