A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

Covering the wound with sterile gauze moistened with normal saline.

Placing the patient in low Fowler's position with knees bent.

Calling for assistance and notifying the surgeon.

Applying pressure to the wound edges.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.

Choice B reason:

Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.

Choice C reason:

Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.

Choice D reason:

Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.

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Correct Answer is ["B"]

Explanation

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client should use a walker or crutches to avoid putting too much weight on the new hip and prevent dislocation or damage to the prosthesis.

Choice B reason:

This statement is incorrect and indicates a need for further teaching. The client should not keep the legs crossed when sitting or lying down, as this can cause dislocation of the new hip joint. The client should keep the affected leg in abduction at all times.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client should avoid bending the hip more than 90 degrees when getting dressed or using the toilet, as this can also cause dislocation of the new hip joint. The client should use assistive devices such as a long-handled reacher or a raised toilet seat.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client should take antibiotics as prescribed to prevent infection, which can be a serious complication of hip replacement surgery. The client should also report any signs of fever, chills, or increased pain.

Choice E reason:

This statement is correct and does not indicate a need for further teaching. The client should report any signs of bleeding, swelling, redness or drainage from the incision, as these can also indicate infection or hematoma formation. The client should keep the incision clean and dry and change the dressing as instructed.

A. Fat embolism B. Pulmonary edema C. Deep vein thrombosis D. Myocardial infarction.

Correct Answer is A

Explanation

Choice A reason:

Fat embolism is a possible complication of ORIF of a fractured hip. A fat embolism occurs when fat droplets from the bone marrow enter the bloodstream and block small blood vessels in the lungs, brain, or other organs. This can cause serious symptoms such as shortness of breath, chest pain, confusion, seizures, or coma. Fat embolism syndrome is more common with fractures of long bones such as the femur.

Choice B reason:

Pulmonary edema is not a likely complication of ORIF of a fractured hip. Pulmonary edema is a condition where fluid accumulates in the lungs, making it difficult to breathe. Pulmonary edema can be caused by heart failure, kidney failure, lung infections, or high altitude. It is not directly related to bone fractures or surgery.

Choice C reason:

Deep vein thrombosis (DVT) is a possible complication of ORIF of a fractured hip. DVT is a blood clot that forms in a deep vein, usually in the leg. DVT can cause pain, swelling, redness, or warmth in the affected area. DVT can also break off and travel to the lungs, causing a pulmonary embolism, which is a life-threatening emergency. DVT is more likely to occur after surgery or prolonged immobility.

Choice D reason:

Myocardial infarction (MI) is not a likely complication of ORIF of a fractured hip. MI is a heart attack that occurs when the blood supply to the heart muscle is interrupted, causing damage or death of the heart tissue. MI can be caused by coronary artery disease, which is the buildup of plaque in the arteries that supply the heart. MI can also be triggered by stress, physical exertion, or other factors. MI is not directly related to bone fractures or surgery. A) Fat embolism B) Pulmonary edema C) Deep vein thrombosis D) Myocardial infarction

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A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client's understanding of postoperative instructions after a total hip replacement surgery. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["B"]

Explanation

The nurse is caring for a client who has just returned from surgery following an open reduction internal fixation (ORIF) of a fractured hip. The nurse should monitor for which of the following complications?

Correct Answer is A

Explanation

A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

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