After surgery, the client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the wound site, the sutures are open and the bowel can be seen protruding from the wound. Which of the following are appropriate nursing interventions? Select all that apply. One, some, or all options may be correct.
Put the patient on NPO status.
Apply a cold compress to the exposed bowel.
Notify the surgical team immediately.
Place dressing dampened with sterile water/saline over the area.
Elevate the head of the bed 90 degrees.
Correct Answer : A,C,D
A. Put the patient on NPO status: Prevents oral intake before surgical evaluation and possible return to the operating room; also reduces risk of aspiration if anesthesia is needed.
B. Apply a cold compress to the exposed bowel: Avoids this -cold compresses can cause vasoconstriction and tissue damage; they are not recommended for exposed viscera.
C. Notify the surgical team immediately: Timely surgical notification is essential because evisceration is an emergency that usually requires operative management.
D. Place dressing dampened with sterile water/saline over the area: A sterile, saline-moistened dressing protects exposed bowel from drying and contamination while awaiting surgical intervention.
E. Elevate the head of the bed 90 degrees: Avoid positioning that increases intra-abdominal pressure; the recommended position is usually low Fowler’s with knees slightly flexed to reduce tension on the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This is normal for patients who are not turning every 2 hours: Prolonged pressure and lack of repositioning increase risk of pressure injury and tissue necrosis. This is a general statement, not a staging classification.
B. Unstageable pressure injury: An unstageable injury is present when full-thickness tissue loss is suspected but the wound base is obscured by slough or eschar, making depth indeterminate -this description fits wounds covered with thick necrotic tissue.
C. Stage I pressure injury: Stage I involves is characterized by intact skin with non-blanchable redness (erythema) of a localized area, usually over a bony prominence.
D. Eschar: Eschar is dead, leathery, often black or brown tissue that adheres to the wound bed; its presence commonly prompts classification as unstageable until the eschar is removed or the base is visible.
Correct Answer is B
Explanation
A. The client can decide when they want to quit using an inhaler: Decisions about stopping controller or maintenance inhaled medications should be made in consultation with the healthcare provider because abrupt cessation may worsen respiratory control.
B. The client should rinse their mouth between uses to avoid candida: Rinsing the mouth and spitting after using inhaled corticosteroids reduces residual medication in the oropharynx and lowers the risk of oral candidiasis and hoarseness.
C. There are no special considerations for inhaled medications: Inhaled meds require proper technique (e.g., spacer use), timing, and post-use mouth care; these considerations affect efficacy and side-effect risk.
D. These medications never cause any changes in vital signs: While inhaled corticosteroids are primarily local, some inhaled agents (especially bronchodilators) can affect heart rate and blood pressure, and high systemic steroid exposure can have systemic effects.
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