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
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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Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
A. Keeping both arms below the level of the client's heart is not recommended for preventing lymphedema. The affected arm should be elevated when possible to reduce the risk of fluid accumulation.
B. Obtaining blood pressure readings on the affected arm is contraindicated because it can increase the risk of lymphedema.
C. Use the client's left arm to obtain blood samples: To prevent lymphedema, it's important to avoid using the affected arm (the right arm in this case) for invasive procedures like blood draws or blood pressure measurements, as this can increase the risk of lymphedema by promoting fluid retention.
D. Limiting range-of-motion exercises could impair recovery and muscle function. Early and gentle exercises should be encouraged to maintain mobility and avoid complications.
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