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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Open the splint: Reduces pressure and alleviates compartment syndrome.

Place the client on NPO status: Anticipated in preparation for possible surgery (e.g., fasciotomy).

Place the leg in a dependent position: Contraindicated as it can worsen swelling and increase pressure.

Obtain a urinalysis: Necessary to monitor for myoglobinuria, a potential complication of muscle damage in compartment syndrome.

A. "There is no cure for MRSA.” B. "We will need to wear masks when we are in the hospital room." C. "MRSA only occurs in health care facilities.” D. "We should remove gloves before leaving the hospital room."

Correct Answer is D

Explanation

A. "There is no cure for MRSA.": MRSA infections can be treated with specific antibiotics.
B. "We will need to wear masks when we are in the hospital room.": Masks are not necessary for contact precautions unless there is an additional indication, such as droplet precautions.
C. "MRSA only occurs in health care facilities.": MRSA can occur in both community and healthcare settings.
D. "We should remove gloves before leaving the hospital room.": Gloves and gowns must be removed inside the room to prevent contamination of the hospital environment.

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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

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?

Correct Answer is D

Explanation

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