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 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

A. "General anesthesia will make you unconscious and unable to feel any pain during the surgery.” B. "General anesthesia will numb your lower body and allow you to remain awake during the surgery.” C. "General anesthesia will block pain signals from reaching your brain and make you sleepy during the surgery.” D. "General anesthesia will relax your muscles and reduce your awareness of what is happening during the surgery."

Correct Answer is A

Explanation

Choice A reason:

General anesthesia will make you unconscious and unable to feel any pain during the surgery. This is true because general anesthesia affects the whole body and brain, blocking the sensation of pain and awareness of the surroundings. General anesthesia is used for almost all laparoscopic hysterectomies and is often used for abdominal and vaginal hysterectomies. General anesthesia also impairs your breathing, so a breathing tube, ventilator, and inhalation anesthetic may be used.

Choice B reason:

General anesthesia will numb your lower body and allow you to remain awake during the surgery. This is false because general anesthesia does not numb only a part of the body, but rather affects the whole body and brain. Numbing only a part of the body is called regional anesthesia, which involves injecting an anesthetic near a cluster of nerves to block pain signals from that area. Regional anesthesia can be used for some types of hysterectomies, but not for abdominal hysterectomy.

Choice C reason:

General anesthesia will block pain signals from reaching your brain and make you sleepy during the surgery. This is partially true but incomplete. General anesthesia does block pain signals from reaching your brain, but it also makes you unconscious, not just sleepy. You will not be aware of anything that is happening during the surgery or remember anything afterwards. General anesthesia also affects other functions of your body, such as breathing, blood pressure, and heart rate.

Choice D reason:

General anesthesia will relax your muscles and reduce your awareness of what is happening during the surgery. This is also partially true but incomplete. General anesthesia does relax your muscles and reduce your awareness, but it also makes you completely unconscious and unable to feel any pain. You will not have any memory of the surgery or be able to respond to any stimuli. General anesthesia also has other effects on your body, such as lowering your body temperature and slowing down your digestion.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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