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:

Placing a pillow under the dependent axilla is a proper technique for lateral positioning because it helps to prevent brachial plexus injury by reducing the pressure on the neurovascular structures in the axilla. It also helps to maintain the alignment of the shoulder and prevent shoulder drop.

Choice B reason:

Flexing both knees at a 90-degree angle is not a proper technique for lateral positioning because it can cause excessive pressure on the knees and ankles, leading to nerve injury or skin breakdown. It can also impair venous return and increase the risk of deep vein thrombosis (DVT) Only the dependent leg should be flexed at the hip and knee, while the upper leg should be straight and supported by pillows between the legs.

Choice C reason:

Aligning the shoulders directly over each other is not a proper technique for lateral positioning because it can cause compression of the dependent shoulder and compromise the blood supply to the arm. It can also cause shoulder drop and brachial plexus injury. The lower shoulder should be pulled slightly forward and supported by a pad under the chest wall.

Choice D reason:

Elevating the dependent arm on an arm board is not a proper technique for lateral positioning because it can cause excessive abduction of the arm and stretch the brachial plexus. It can also interfere with surgical access to the thorax or kidney. Both arms should be supported on parallel arm boards with abduction less than 90 degrees.

A. Double gloving. B. Placing instruments in closed containers at completion of surgery. C. Wearing shoe covers in addition to personal protective equipment. D. Using instruments only from specially marked trays.

Correct Answer is A

Explanation

Choice A reason:

Double gloving is a recommended precaution for health care workers who are exposed to blood or body fluids of clients who have a positive HIV test result. Double gloving can reduce the risk of needlestick injuries and transmission of HIV or other bloodborne pathogens.

Choice B reason:

Placing instruments in closed containers at completion of surgery is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Placing instruments in closed containers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice C reason:

Wearing shoe covers in addition to personal protective equipment is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Wearing shoe covers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice D reason:

Using instruments only from specially marked trays is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Using instruments only from specially marked trays does not protect the health care workers from exposure to blood or body fluids during 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

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Explanation

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Explanation

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