The nurse enters a client's room to find that his abdominal wound has eviscerated.
Which intervention should the nurse implement first?

Place the client in reverse Trendelenburg position

Administer IV antibiotics STAT

Use sterile gloves to replace the protruding parts

Apply a sterile normal saline dressing

Answer and Explanation

The Correct Answer is D

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

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Correct Answer is C

Explanation

Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites.

Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve.

Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle.

Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

A. administration can predict overtime costs more accurately. B. skills of the nursing team can be used more effectively. C. clients receive less attention because there are too many staff members involved in the care. D. nurses report more pressure to perform necessary tasks themselves.

Correct Answer is B

Explanation

Choice A rationale: Administration predicting overtime costs is not a recognized advantage of delegation.

Choice B rationale: Skills of the nursing team can be used more effectively, allowing tasks to be delegated to the appropriate individuals and promoting efficient care delivery.

Choice C rationale: Clients do not necessarily receive less attention due to delegation if it is done effectively.

Choice D rationale: Nurses reporting more pressure to perform necessary tasks themselves is not a recognized advantage of delegation.

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The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client. Assuming that there are no skin problems, which is the preferred site for the injection?

Correct Answer is C

Explanation

An advantage of delegation in client care is that:

Correct Answer is B

Explanation

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The nurse enters a client's room to find that his abdominal wound has eviscerated.
Which intervention should the nurse implement first?