The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Apply a sterile normal saline dressing

Use sterile gloves to replace the protruding parts

Administer IV antibiotics STAT

Place the client in reverse Trendelenburg position

Answer and Explanation

The Correct Answer is A

A. if a client's abdominal wound has eviscerated, the first intervention should be to apply a sterile normal saline dressing to the area and then seek immediate medical assistance.

B. Using sterile gloves to replace the protruding parts is not recommended since it can result in further damage of the organs.

C. Administering IV antibiotics may be indicated later but is not the first priority.

D. Placing the client in reverse Trendelenburg position is not the first priority and may not be appropriate for managing evisceration.

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Correct Answer is B

Explanation

A. Using a 1 ml syringe with a 5/8 inch needle for administering 0.5 ml of heparin subcutaneously is appropriate.

B. The instructor should intervene if the student is instructing a client to place a buccal medication under the tongue, as buccal medications should be placed in the cheek pouch, not under the tongue, which is the correct method for sublingual medications.

C. Injecting air into a vial before withdrawing medication is a standard practice to equalize pressure and facilitate withdrawal.

D. Pouring the ordered medication "Robitussin 2 tsp. now" to the 10 ml mark on a medication cup is correct since 1 tsp. is approximately 5mls.

A. Anorexia B. Flushing/warmth of the skin C. Neuromuscular irritability D. Paresthesia

Correct Answer is C

Explanation

A. Anorexia is not typically associated with low serum magnesium levels.

B. Flushing/warmth of the skin is not typically associated with low serum magnesium levels.

C. Neuromuscular irritability, including muscle twitching, tremors, and spasms, is a common sign of hypomagnesemia (low serum magnesium levels).

D. Paresthesia (tingling or numbness) is more commonly associated with hypocalcemia rather than hypomagnesemia.

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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 nursing Instructor is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student requires intervention by the instructor?

Correct Answer is B

Explanation

A client has a serum magnesium level of 0.9 mEq/L. The nurse would monitor this client for which sign or symptom?

Correct Answer is C

Explanation

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