A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Cover the area with saline-soaked sterile dressings.

Gently suction secretions from the wound bed using a 12 gauge sterile catheter.

Answer and Explanation

The Correct Answer is C

A. Placing pressure on exposed organs is not appropriate and could cause further damage.

B. Having the client lie supine with legs straight could increase tension on the abdominal wound and exacerbate the evisceration.

C. Covering the eviscerated organs with saline-soaked sterile dressings is the correct intervention to protect the organs from infection and prevent them from drying out while waiting for emergency surgical intervention.

D. Suctioning secretions from the wound bed is not appropriate and could cause additional trauma to the exposed organs.

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Correct Answer is C

Explanation

A. Albuterol may be used to treat bronchospasm associated with anaphylaxis, but it is not the first-line treatment.

B. Hydrocortisone sodium succinate is a corticosteroid that can help reduce inflammation, but it is not the first-line treatment in acute anaphylaxis.

C. Epinephrine is the first-line treatment for anaphylactic shock. It acts quickly to constrict blood vessels, increase heart rate, and open airways, counteracting the severe allergic reaction.

D. Diphenhydramine is an antihistamine that can help alleviate allergic symptoms but should be given after epinephrine in anaphylactic emergencies.

A. Administer the medication. B. Review the effects of the pain medication. C. Determine the location of the pain. D. Reposition the client.

Correct Answer is C

Explanation

A. Administering pain medication should be done after assessing the pain to ensure appropriate treatment.

B. Reviewing the effects of the pain medication is important but should be done after determining the specifics of the pain.

C. The first step in pain management is to assess the pain, including its location, intensity, and characteristics, to ensure that the appropriate treatment is provided.

D. Repositioning the client might help alleviate pain, but it should be considered after assessing the pain.

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A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

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