A nurse on the Medical-Surgical unit is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.).
Offer a glass of water to the patient.
Monitor the patient for signs and symptoms of shock.
Place moist sterile gauze over the site.
Gently place the organs back.
Contact the patient's Surgeon.
Correct Answer : B,C,E
Choice A rationale:
Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.
Choice B rationale:
Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.
Choice C rationale:
Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.
Choice D rationale:
Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.
Choice E rationale:
Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Reporting the incident to the charge nurse is important, but it's not the first action to take in this situation. The immediate concern should be addressing the potential exposure to bloodborne pathogens.
Choice B rationale:
This is the correct choice. Washing the area of the puncture thoroughly with soap and water is the first step the nurse should take after an accidental needlestick. It helps reduce the risk of infection by cleaning the wound and removing any potential contaminants.
Choice C rationale:
Going to employee health services is a valid step, but it's not the immediate action needed after an accidental needlestick. Cleaning the wound should come first.
Choice D rationale:
Completing an incident report is important for documentation purposes, but it is not the nurse's first priority in this situation. Immediate wound care takes precedence.
Correct Answer is D
Explanation
Choice D rationale:
This statement by an assistive personnel (AP) indicates a need for further teaching. Hand hygiene is crucial to prevent the transmission of microorganisms, and it involves both handwashing and the appropriate use of gloves. Changing gloves between clients is important to prevent cross-contamination, but it doesn't replace the need for handwashing. Hands can become contaminated even with the use of gloves, and proper hand hygiene should be practiced before and after glove use.
Choice A rationale:
The statement about using alcohol-based hand products after most client contact is accurate. Alcohol-based hand sanitizers are effective in reducing the number of microorganisms on the hands when soap and water are not readily available. They are especially useful in healthcare settings.
Choice B rationale:
Washing hands before providing client care is a fundamental principle of infection control. It helps remove dirt, debris, and transient microorganisms from the hands, reducing the risk of infection transmission.
Choice C rationale:
The statement about not wearing artificial nails when providing client care is correct. Artificial nails can harbor microorganisms and are challenging to clean thoroughly. They pose an infection risk and are generally not recommended for healthcare workers who provide direct patient care.
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