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. Withhold the feeding if the residual volume is 150 mL — A residual volume of 150 mL may not necessarily require withholding the feeding. The threshold for withholding feedings is generally higher, typically around 250-500 mL, depending on the facility's protocol.
B. Flush the tube with 30 mL of sterile water before the feeding — It is standard practice to flush the NG tube with 30 mL of sterile water before administering the feeding to ensure the tube is patent and to prevent clogging.
C. Cleanse the top of the can of formula with an alcohol wipe — The proper action is to cleanse the top of the can with soap and water, not alcohol. Alcohol may leave residues that can contaminate the formula.
D. Keep the formula cold until instillation — Formula should be kept at room temperature to avoid discomfort and to prevent slow gastric emptying due to cold temperatures.
Correct Answer is A
Explanation
A. Dehydration — Vomiting causes the loss of fluids and electrolytes, which increases the risk of dehydration. The body loses water, sodium, and potassium, leading to dehydration, which is a common complication of vomiting.
B. Urinary frequency — Urinary frequency is not typically associated with vomiting. In fact, dehydration could result in decreased urine output, not increased frequency.
C. Peripheral edema — Peripheral edema is usually related to fluid retention, which is the opposite of dehydration. Vomiting typically does not lead to edema.
D. Diarrhea — Diarrhea is a separate gastrointestinal issue, typically caused by infections or gastrointestinal irritation, not by vomiting.
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