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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale: The normal stimulus to breathe is an increased carbon dioxide level, which stimulates the respiratory center in the brain.
Choice B rationale: Increased oxygen levels do not serve as the primary stimulus for breathing. The respiratory center is primarily responsive to carbon dioxide levels.
Choice C rationale: Increased carbon dioxide level is the correct stimulus for normal breathing.
Choice D rationale: Decreased oxygen level is not the primary stimulus for normal breathing.
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