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. A wound infection. B. A wound dehiscence. C. A wound evisceration. D. A wound hematoma.

Correct Answer is A

Explanation

Choice A reason:

A wound infection is the most likely diagnosis for a client who has redness, warmth, swelling, and purulent drainage at the incision site 24 hours after an appendectomy. These are signs of inflammation and infection that indicate the wound is not healing properly. A wound infection can delay wound healing, increase pain, and cause fever and systemic symptoms. A wound infection requires treatment with antibiotics and wound care.

Choice B reason:

A wound dehiscence is a partial or complete separation of the edges of a surgical incision. It usually occurs later than 24 hours after surgery, when the wound is still fragile and weak. A wound dehiscence can be caused by stress on the wound, such as coughing, vomiting, or straining, or by poor wound closure, infection, or malnutrition. A wound dehiscence may present with increased drainage, a visible gap in the incision, or a popping sensation. A wound dehiscence requires immediate medical attention and may need surgical repair.

Choice C reason:

A wound evisceration is a rare but serious complication of a wound dehiscence, where the abdominal organs protrude through the open incision. It is a surgical emergency that requires immediate intervention to prevent organ damage, infection, and shock. A wound evisceration may present with sudden pain, a gush of blood or serous fluid, and visible organs through the wound. The client should lie down with knees bent and cover the wound with a sterile dressing moistened with warm saline until help arrives.

Choice D reason:

A wound hematoma is a collection of blood under the skin or in the deeper tissues that results from bleeding at the surgical site. It usually occurs within the first few hours after surgery and may cause swelling, pain, bruising, and pressure on nearby structures. A wound hematoma can increase the risk of infection and impair wound healing. A small hematoma may resolve on its own, while a large hematoma may need drainage or surgery.

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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

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

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Correct Answer is A

Explanation

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