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 ["1.5"]

Explanation

To calculate the volume of morphine injection required to administer a dose of 15 mg when the available concentration is 10 mg/mL, the nurse should use the formula: Volume (mL) = Dose (mg) / Concentration (mg/mL). Plugging in the values, the calculation would be: Volume (mL) = 15 mg / 10 mg/mL. This simplifies to 1.5 mL.

A. Restlessness B. Heart rate 110/min C. Respiratory rate 28/min D. Pink mucous membranes

Correct Answer is D

Explanation

A. Restlessness is a sign of hypoxia, indicating that oxygenation might still be inadequate.

B. A heart rate of 110/min suggests tachycardia, which can also be associated with ongoing hypoxia.

C. A respiratory rate of 28/min is elevated and may indicate continued respiratory distress or hypoxia.

D. Pink mucous membranes are a sign of adequate oxygenation and indicate that the supplemental oxygen is effective in resolving the hypoxia.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

A nurse is assisting with the care of a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?

Correct Answer is D

Explanation

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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?

A nurse is assisting in providing care for a client who has obstructive shock. Which of the following diagnoses should the nurse expect?