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.

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Correct Answer is C

Explanation

A. Palpate the client’s pulse at the third intercostal space:
The apical pulse is at the fifth intercostal space, midclavicular line-not the third. The third is not standard for pulse assessment.

B. Ask the client to perform the Valsalva maneuver:
This can be used in arrhythmias like supraventricular tachycardia but is not appropriate for assessment of irregular rhythm.

C. Auscultate the client’s apical pulse:
This is the most accurate way to assess an irregular pulse, especially for one full minute.

D. Check the client’s heart rate for 30 sec:
When a rhythm is irregular, you must assess for a full minute, not 30 seconds.

A. Ask the client to cough every 4 hr. B. Decrease the head of the client's bed. C. Encourage the client to take deep breaths. D. Request a prescription for an opioid analgesic.

Correct Answer is C

Explanation

A. Ask the client to cough every 4 hr:
Coughing can help clear secretions, but doing so only every 4 hours is not sufficient for hypoxia. More immediate action is needed.

B. Decrease the head of the client’s bed:
Lowering the head of the bed reduces lung expansion and worsens oxygenation.

C. Encourage the client to take deep breaths:
Deep breathing improves alveolar expansion and oxygen exchange, which helps raise oxygen saturation.

D. Request a prescription for an opioid analgesic:
Opioids can depress respiratory drive, further lowering oxygen levels unless pain is clearly affecting breathing.

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