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 D

Explanation

A. Consuming clear liquids up to the time of surgery is generally not allowed due to the risk of aspiration during anesthesia.

B. Tongue studs and other jewelry should be removed before surgery to prevent injury or interference with medical equipment.

C. Taking morning vitamins before surgery is typically not permitted unless specifically allowed by the healthcare provider, as they can affect anesthesia or surgical outcomes.

D. Allowing the client to keep her hearing aids in until the last possible moment helps with communication, reduces anxiety, and ensures the client can hear important information during pre-operative preparations.

A. "Activation of the inflammatory cascade causes increased perfusion." B. The major organ prone to injury during SIRS is the heart." C. Spleen dysfunction causes blood clotting issues." D. "A deregulated cytokine storm causes an inflammatory response."

Correct Answer is D

Explanation

A. Activation of the inflammatory cascade in SIRS typically leads to decreased perfusion and tissue damage due to widespread inflammation and capillary leakage.

B. SIRS can affect multiple organs, but it is particularly known for impacting the lungs and kidneys rather than the heart.

C. While SIRS can involve coagulation issues, these are not specifically due to spleen dysfunction but rather to the widespread inflammatory response.

D. SIRS is driven by a deregulated cytokine storm, which leads to an excessive and uncontrolled inflammatory response, potentially resulting in multiple organ failure.

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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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Explanation

A nurse is assisting in explaining the pathophysiology of systemic inflammatory response syndrome (SIRS) to a group of newly licensed nurses. Which of the following statements by the nurse is accurate?

Correct Answer is D

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