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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.

Notify the surgeon

Place the client in low-Fowler's with knees raised

Start a peripheral IV (PIV)

Cover the wound with moistened sterile gauze

Hold pressure on the dressing

Encourage the client to drink fluids

Assist the client to cough and deep breathe

Answer and Explanation

Correct Answer : A,C,D

A. Notify the surgeon: The client has developed a wound dehiscence with evisceration of intestinal tissue, which is a serious surgical complication. Immediate communication with the surgeon is necessary to determine the next steps for repair and to avoid further complications, such as infection or organ injury.

B. Place the client in low-Fowler's with knees raised: While positioning is important for comfort and reducing pressure on the abdomen, placing the client in low-Fowler’s position is not the priority. The focus should be on protecting the eviscerated tissue and managing potential hypovolemia.

C. Start a peripheral IV (PIV): Starting a PIV is essential for administering fluids and medications, especially if the client requires resuscitation or further surgical intervention. The client's vital signs (decreased blood pressure, increased heart rate) suggest potential hypovolemia or shock, which may require IV fluids for stabilization.

D. Cover the wound with moistened sterile gauze: Evisceration requires immediate intervention to protect the exposed tissue. The nurse should cover the wound with sterile gauze that is moistened with normal saline to prevent the exposed intestines from drying out and to reduce the risk of infection. This is a critical step in managing the wound before further surgical intervention.

E. Hold pressure on the dressing: Applying pressure to the surgical dressing is not appropriate in this situation because it could cause more harm or further disrupt the wound. The wound should be covered with moistened sterile gauze to protect the eviscerated tissue, not pressured.

F. Encourage the client to drink fluids: Oral intake is not appropriate in the acute post-surgical phase when the client has experienced evisceration. The client may require surgical repair, and fluids should be administered intravenously to avoid the risk of aspiration or bowel perforation.

G. Assist the client to cough and deep breathe: While respiratory exercises are important for preventing atelectasis and pneumonia post-operatively, they are not an immediate priority in this situation where the client has evisceration. Stabilizing the wound and addressing potential shock takes precedence.

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

Explanation

Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.

A. Auscultate an area six inches below the umbilicus. B. Measure the girth of the client's lower abdomen. C. Observe the appearance of the client's urine. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

A. Auscultation is generally used to assess bowel sounds or lung sounds, not urinary retention.

B. Measuring girth may be useful for assessing ascites or other fluid retention but is not specific to urinary retention.

C. Observing the appearance of urine is not directly useful for detecting retention. Retention is about the inability to void despite the urge, and urine may or may not be visibly affected.

D. Palpation above the pubic symphysis is the most effective way to assess for urinary retention because the bladder is located in this area. A distended bladder, which is a sign of retention, can often be palpated here.

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Patient Data Exhibits Which should the nurse immediately do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

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Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.