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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 D

Explanation

A. Speak to the healthcare provider about instituting physical therapy: Physical therapy is not necessary in the immediate period before surgery for hypertrophic pyloric stenosis.
B. Ensure placement of the nasogastric tube with an abdominal x-ray: While confirming tube placement is important, it is not a key action for maintaining growth and development.
C. Use sterile water for gastric lavage: This is not relevant to the care of a child with hypertrophic pyloric stenosis in the pre-surgical period.
D. Offer a pacifier for nonnutritive sucking: Non-nutritive sucking provides comfort and can promote normal development in infants, even in the absence of feeding.

A. Lay prone for 24 hours after the procedure. B. Report any painful urination, blood in urine, or fever. C. Avoid strenuous activity and sports for at least 2 weeks. D. Report any allergies to shellfish or iodine.

Correct Answer is B

Explanation

A. Lay prone for 24 hours after the procedure. There is no need for the client to lay prone after a cystoscopy. The client can usually return to normal activities with rest.

B. Report any painful urination, blood in urine, or fever. These are potential complications after a cystoscopy, and the client should be instructed to report them promptly to prevent further complications like infection or hemorrhage.

C. Avoid strenuous activity and sports for at least 2 weeks. Although rest is encouraged, the specific recommendation about avoiding activity for 2 weeks is not generally required unless specified by the provider.

D. Report any allergies to shellfish or iodine. While iodine allergies can affect contrast used in imaging studies, they are not related to cystoscopy procedures, which typically do not use contrast agents.

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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 D

Explanation

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Correct Answer is B

Explanation

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Patient Data

Exhibits

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