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 D
Explanation
Choice A rationale:
Helping the client select a low-salt diet is not directly related to addressing tenacious bronchial secretions. While a low-salt diet might have some implications for overall cardiovascular health, it doesn't specifically address the issue of secretions in the lungs.
Choice B rationale:
Encouraging the client to drink 2 to 3 L of water daily is generally beneficial for maintaining hydration and thinning mucus secretions. However, it doesn't directly address the problem of not being able to bring up secretions. Other interventions are more suitable for that issue.
Choice C rationale:
Administering oxygen via nasal cannula at 2 L/min can provide respiratory support, but it doesn't directly address the problem of tenacious bronchial secretions. Oxygen therapy primarily aims to improve oxygenation, not facilitate mucus clearance.
Choice D rationale:
This is the correct choice. Maintaining a semi-Fowler's position (head of the bed elevated to approximately 30-45 degrees) can help improve lung expansion and facilitate drainage of bronchial secretions. This position helps to reduce the pooling of secretions in the airways, making it easier for the client to cough and bring up the mucus.
Correct Answer is D
Explanation
The correct answer is choice D - "Eating a high fiber diet will reduce my risk for developing skin cancer."
Choice A rationale:
Checking the skin monthly for any changes is a recommended practice for early detection of skin cancer. Changes in the size, color, shape, or appearance of moles or spots can be indicative of skin cancer. This statement demonstrates understanding and does not require further teaching.
Choice B rationale:
Avoiding the use of tanning booths is a crucial recommendation for preventing skin cancer. Tanning booths emit ultraviolet (UV) radiation, which significantly increases the risk of skin cancer. This statement reflects accurate knowledge and does not indicate a need for further teaching.
Choice C rationale:
Using sunscreen even on cloudy days is a sound practice to prevent skin cancer. UV rays can penetrate clouds and cause skin damage even when the sun is not directly visible. This statement shows good understanding and does not require further teaching.
Choice D rationale:
Eating a high fiber diet will reduce my risk for developing skin cancer - This statement indicates a need for further teaching. While a high fiber diet has various health benefits, it is not directly linked to reducing the risk of developing skin cancer. Skin cancer prevention primarily involves sun protection measures, avoiding tanning beds, and regular skin checks. The nurse should clarify the correct strategies for preventing skin cancer.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.