A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Trendelenburg with legs extended

Supine with knees flexed

Semi-Fowler's with legs extended

Left-lateral with knees flexed

Answer and Explanation

The Correct Answer is B

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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Correct Answer is C

Explanation

A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

A. Apply pressure to the venipuncture site with sterile gauze. B. Perform hand hygiene. C. Clamp the IV tubing. D. Withdraw the catheter from the client's vein. E. Remove the dressing and tape from the venipuncture site.

Correct Answer is B,E,C,A,D

Explanation

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

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A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,E,C,A,D

Explanation

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