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: Poor tissue perfusion from circulatory insufficiency can affect oxygenation, but fluid in the lungs primarily impacts gas exchange at the alveolar level.

Choice B rationale: Decreased diffusion of oxygen from the alveoli to the blood is a major factor affecting oxygenation when fluid is present in the lungs.

Choice C rationale: Lowered oxygen carrying capacity can affect oxygenation but is not the primary concern in the presence of fluid in the lungs.

Choice D rationale: Decreased concentration of oxygen in the air is not the primary factor affecting oxygenation in a client with fluid in the lungs.

A. tell the nurse manager. B. notify the physician. C. check the client's blood pressure. D. file an incident report.

Correct Answer is C

Explanation

Choice A rationale: Telling the nurse manager is not the first action; the immediate focus should be on the client's well-being.

Choice B rationale: Notifying the physician is important, but the immediate concern is addressing the client's condition.

Choice C rationale: Checking the client's blood pressure is the first action to assess the client's response to the medication error.

Choice D rationale: Filing an incident report is important for documenting the error but is not the immediate action in this situation.

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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

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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?