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 B
Explanation
A. Assisting the client to a low Fowler's position (15 to 30 degrees) is not appropriate for enteral feedings. The client should be positioned at a higher angle (30 to 45 degrees) to reduce the risk of aspiration and improve digestion during feeding.
B. Testing the pH of gastric aspirate is essential to confirm that the NG tube is in the correct position (i.e., the stomach). A pH of 1 to 4 indicates gastric placement, while higher pH values suggest the tube may be in the lungs or intestines. This is a crucial step to ensure safety before administering the feeding.
C. Discarding residual gastric contents is not the correct action. Residual gastric contents should be measured to assess gastric motility and tolerance to the feeding. The feeding should only be withheld if the residual volume is excessive, based on institutional guidelines.
D. Warming the feeding solution to body temperature is not always necessary, although it is often recommended to improve comfort and prevent cramping. The most important step is confirming tube placement and ensuring the feeding is safe.
Correct Answer is D
Explanation
A. Increased collagen is not a direct risk factor for pressure injuries. Collagen plays a role in wound healing but does not increase the risk of developing pressure ulcers.
B. Increased muscle mass does not increase the risk for pressure injuries. In fact, more muscle mass can help protect against pressure ulcers by distributing weight and pressure more evenly.
C. Decreased serum calcium can contribute to weakened bones and muscle function, but it is not a primary factor in the development of pressure injuries.
D. Decreased circulation is a major risk factor for pressure injuries. Impaired mobility often leads to prolonged pressure on certain areas of the body, reducing blood flow to those areas. This lack of circulation can cause tissue ischemia, leading to pressure injuries.
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