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Patient Data

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

Notify the surgeon

Assist the client to cough and deep breathe

Encourage the client to drink fluids

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

Cover the wound with moistened sterile gauze

Hold pressure on the dressing

Start a peripheral IV (PIV)

Answer and Explanation

Correct Answer : A,D,E,G

A. Notify the surgeon: The client is experiencing wound evisceration, a surgical emergency. Immediate notification of the surgeon is essential to prepare for urgent surgical repair and prevent further tissue damage or infection.

B. Assist the client to cough and deep breathe: This increases intra-abdominal pressure and could worsen the evisceration. It is contraindicated in clients with open abdominal wounds and protruding organs.

C. Encourage the client to drink fluids: Oral intake is not appropriate when surgery is likely imminent. The client should remain NPO to reduce aspiration risk during anesthesia for emergent wound closure.

D. Place the client in low-Fowler’s with knees raised: This position helps decrease tension on the abdominal wall and limits further protrusion of abdominal contents. It also promotes comfort while reducing strain on the wound.

E. Cover the wound with moistened sterile gauze: Covering the exposed intestines with sterile saline-moistened gauze protects tissue from drying, contamination, and infection until surgical repair can occur.

F. Hold pressure on the dressing: Applying pressure to eviscerated organs can cause trauma and worsen the injury. This action is inappropriate and unsafe in cases of abdominal wound dehiscence with evisceration.

G. Start a peripheral IV (PIV): IV access is necessary to administer fluids, medications, and prepare for possible surgery. Establishing a reliable IV line is a priority in managing surgical emergencies like evisceration.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Cleanse the perineal area in circular motion after voiding: Cleaning should be done from front to back, not in a circular motion, to prevent introducing bacteria from the anal area to the urethra.

B. Drink large amounts of fluids before bedtime: Drinking large amounts before bed can lead to bladder distention and nighttime urgency, which may not effectively prevent infection and can disrupt sleep.

C. Empty the bladder before and after sexual intercourse: Voiding before and after intercourse helps flush out bacteria introduced into the urethra during sexual activity, significantly reducing the risk of UTI.

D. Hold urine for at least 10 minutes to dilute bacteria: Holding urine encourages bacterial growth by allowing urine to remain stagnant in the bladder longer, increasing the risk of infection rather than preventing it.

A. Infectious process in the synovial fluid. B. Systemic inflammatory response. C. Destruction of joint cartilage. D. Loss of bone mineral density.

Correct Answer is C

Explanation

A. Infectious process in the synovial fluid: An infection in the synovial fluid would suggest septic arthritis, not osteoarthritis, which is a degenerative, non-infectious joint condition.

B. Systemic inflammatory response: A systemic inflammatory response is characteristic of autoimmune diseases like rheumatoid arthritis, not the localized wear-and-tear process of osteoarthritis.

C. Destruction of joint cartilage: Osteoarthritis involves the gradual breakdown and loss of cartilage, leading to pain, stiffness, and decreased joint mobility as bone surfaces begin to rub against each other.

D. Loss of bone mineral density: Loss of bone mineral density is related to osteoporosis, a different condition that affects bone strength but does not primarily cause joint pain and stiffness.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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Patient Data

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