A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a sterile normal saline soaked dressing.

Apply an abdominal binder to the wound area.

Assure the client that this is an expected occurrence after surgery.

Turn the client onto her side.

Answer and Explanation

The Correct Answer is A

A. Cover the wound with a sterile normal saline soaked dressing:
This keeps the exposed organs moist and reduces infection risk until surgical intervention.

B. Apply an abdominal binder to the wound area:
This can increase pressure and cause further damage to exposed organs.

C. Assure the client that this is an expected occurrence after surgery:
Evisceration is a surgical emergency, not expected.

D. Turn the client onto her side:
The client should be placed in a low Fowler’s position with knees bent to reduce abdominal strain-not on the side.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Elevate the client’s arm above the level of the heart:
This may falsely lower the reading. The arm should be at heart level.

B. Align the artery indicator on the BP cuff with the client’s brachial artery:
Correct alignment ensures accurate readings. Most cuffs have an arrow or line that must align with the brachial artery.

C. Place the BP cuff 5 cm (2 in) above the client’s antecubital space:
The cuff should be placed about 2.5 cm (1 inch) above the antecubital space-not 5 cm.

D. Select a cuff that covers 50% of the client’s upper arm:
The correct cuff should cover at least 80% of the arm’s circumference, not 50%, for accurate readings.

A. Temperature of 39° C (102.2° F). B. Hypoglycemia C. Report of dizziness D. History of cigarette smoking

Correct Answer is C

Explanation

A. Temperature of 39°C (102.2°F):
Fever typically causes an increase in heart rate, not bradycardia.

B. Hypoglycemia:
Hypoglycemia is more commonly associated with tachycardia, sweating, and tremors, not bradycardia.

C. Report of dizziness:
Bradycardia (HR <60/min) can lead to decreased cardiac output and cerebral perfusion, causing dizziness.

D. History of cigarette smoking:
Smoking is associated with cardiovascular disease but not specifically bradycardia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

A nurse is collecting data on a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client. Exhibits Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device (wound vac) placed over it. Which of the following findings by the nurse, during a dressing change, indicates healing of the wound?

A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?