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: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.

Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.

Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.

Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.

A. Shared responsibility B. Mutual independence C. Working in the same department D. Common purpose

Correct Answer is C

Explanation

Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.

Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.

Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.

Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.

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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 best way for the nurse to assess a client's level of dyspnea is to:

Correct Answer is B

Explanation

The nurse recognizes that which is not a necessary feature of a team?

Correct Answer is C

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?