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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Decrease the temperature in the client’s room:
This would worsen hypothermia. The room should be warm.
B. Place a cooling fan near the client:
Cooling is used for fevers, not hypothermia.
C. Place a warming blanket over the client:
This is a first-line intervention for mild hypothermia. It helps raise the core temperature.
D. Request a prescription for an antipyretic medication:
Antipyretics are used to reduce fever, not to treat hypothermia.
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