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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
A. The forming stage is characterized by initial introductions and getting to know one another. It is a period of orientation and exploration rather than problem-solving and high productivity.
B. In the performing stage, the group has resolved its conflicts, established its roles and norms, and is focused on achieving its goals. Members work collaboratively, communicate effectively, and are committed to the success of the group's endeavors.
C. While norming involves the establishment of group norms and cohesion, it typically occurs after the storming stage where conflicts are resolved. Norming focuses on solidifying relationships and establishing effective communication rather than achieving high productivity.
D. The storming stage involves conflicts and disagreements as individuals establish their roles and assert themselves within the group. It is a period of tension and potential power struggles rather than high productivity and problem-solving.
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