Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Identify information as late entry in the record. This action would only be necessary after the issue is resolved and documentation is restored.
B. Print electronic medical record (EMR) from backup server. While printing from the backup server is an option, notifying IT should be done first to address the root cause of the issue.
C. Notify Information services department of the situation. The IT department can assist in troubleshooting the issue and restoring the system to normal function.
D. Wait for notification that the system has been rebooted. It’s important to act proactively by notifying IT to help resolve the problem.

A. Determine the diameter and depth of a client's dermal ulcer. B. Evaluate a client's mobility progress toward the plan of care. C. Titrate oxygen to the prescribed parameters. D. Procure platelet products from the blood bank.

Correct Answer is D

Explanation

A. Determining the diameter and depth of a dermal ulcer requires clinical assessment and should be done by a nurse (RN or PN).

B. Evaluating a client's mobility progress requires clinical judgment to assess the effectiveness of interventions, which is the responsibility of a nurse.

C. Titrating oxygen involves adjusting the oxygen flow based on clinical criteria, which is a nursing responsibility requiring assessment skills and judgment.

D. Procure platelet products from the blood bank is within the scope of practice for UAPs, as it involves logistical tasks that do not require clinical judgment or assessment.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

Correct Answer is D

Explanation

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Drag from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?

Patient Data

Exhibits

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