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 D

Explanation

Choice A rationale: The sclera by the outer canthus is not the typical site for administering eyedrops bilaterally.

Choice B rationale: Dropping medication onto the center of the cornea is not the recommended technique for administering eyedrops.

Choice C rationale: The sclera by the inner canthus is not the usual site for administering eyedrops bilaterally.

Choice D rationale: The lower conjunctival sac is the appropriate area for administering eyedrops, ensuring proper absorption and distribution.

A. dilute potassium elixir in juice prior to administration. B. monitor intake and output every shift C. assess the client for muscle weakness and flaccid paralysis. D. encourage intake of orange juice or a banana with each meal E. obtain a physician's order for cardiac monitoring

Correct Answer is ["C","E"]

Explanation

Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.

Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.

Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.

Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.

Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.

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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

A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

Correct Answer is D

Explanation

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

Correct Answer is ["C","E"]

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?