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 A
Explanation
A. Facilitates the absorption of vitamins — Fats are essential for the absorption of fat-soluble vitamins (A, D, E, and K). These vitamins dissolve in fat and are absorbed into the body via the digestive system.
B. Regulates nerve cell transmission — While fats (specifically omega-3 fatty acids) play a role in brain function and cellular health, nerve cell transmission is primarily regulated by the nervous system and electrolytes, not directly by fats.
C. Builds and repairs tissue — Proteins are the primary nutrients responsible for building and repairing tissues, not fats.
D. Convert to sugar to provide energy — Carbohydrates, not fats, are primarily converted to glucose (sugar) for energy. Fats provide a concentrated source of energy, but they are metabolized into fatty acids and glycerol, not sugar.
Correct Answer is C
Explanation
A. Administering the feeding through a syringe barrel by gravity is an appropriate method for intermittent feedings. It is important to control the rate of administration, and gravity is commonly used for this purpose in tube feedings.
B. Aspirating gastric residuals to check for the amount of remaining formula is a standard practice before administering a tube feeding. The nurse should typically hold off on the feeding if the residual volume exceeds a certain threshold, typically 250-500 mL depending on facility guidelines. However, 50 mL of residual would not typically be a concern.
C. Allowing the client to rest in a supine position during feeding is unsafe. The client should be kept in a semi-Fowler's position (at least 30-45 degrees) to reduce the risk of aspiration and ensure that the feeding is properly digested.
D. Irrigating the NG tube with tap water after feeding is acceptable. It is common to use tap water to ensure that the tube is patent and clear, unless specific guidelines suggest otherwise.
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