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 B

Explanation

Choice A rationale: Propranolol 10 mg PO twice a day would typically be given with a more extended interval between doses, not at 10:00 AM, 2:00 PM, and 6:00 PM.
Choice B rationale: Diazepam 5 mg PO three times a day would align with the specified dosing schedule of 10:00 AM, 2:00 PM, and 6:00 PM.
Choice C rationale: Cephalexin 500 mg PO q4 hours would require more frequent dosing than the specified schedule.
Choice D rationale: Morphine Sulfate 10 mg IM q4 hours prn pain is ordered every 4 hours, not at the specified times of 10:00 AM, 2:00 PM, and 6:00 PM.

A. inject air into the regular insulin, then into the NPH. B. inject air into both vials and withdraw the regular insulin first. C. Inject air into and withdraw the NPH immediately. D. withdraw the regular insulin first.

Correct Answer is B

Explanation

Choice A rationale: Injecting air into the regular insulin and then into the NPH is not the correct sequence.

Choice B rationale: Injecting air into both vials and withdrawing the regular insulin first is the correct sequence when drawing up a combination of short-acting and intermediate- acting insulins.

Choice C rationale: Injecting air into and withdrawing the NPH immediately is not the correct sequence.

Choice D rationale: Withdrawing the regular insulin first is not the correct sequence when preparing a mixed insulin injection.

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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?

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Naxlex Comprehensive Predictor Exams

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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?