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 C

Explanation

A. The highest effective drug concentration in the blood is associated with peak levels, not trough levels.

B. The point at which medication becomes toxic is associated with peak levels, not trough levels.

C. The trough level is associated with the lowest blood serum drug concentration, just before the next dose is administered.

D. The point at which the medication concentration is half of what it was when administered is associated with the half-life of the drug, not trough levels.

A. usual nutritional intake. B. degree of physical activity. C. skin exposure to moisture. D. food and drug allergies. E. ability to respond to pressure-related discomfort.

Correct Answer is ["A","B","C","E"]

Explanation

A. Assessing usual nutritional intake helps identify potential risk factors for poor wound healing and pressure injury development.

B. Assessing the degree of physical activity helps determine the client's mobility level and risk for pressure injuries.

C. Assessing skin exposure to moisture helps identify potential areas of skin breakdown and pressure injury development.

D. While important, assessing food and drug allergies is not directly related to pressure injury risk reduction.

E. Assessing the client's ability to respond to pressure-related discomfort helps identify clients who may be at increased risk for pressure injuries due to decreased mobility or sensory deficits.

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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 nurse is giving an IV anti-infective agent to a client and must hold the dose until the results of the trough level are known. This term is associated with the point at which the:

Correct Answer is C

Explanation

The staff nurses have just received an inservice presentation about pressure Injury risk reduction in their clients. Which points should have been Included? (SELECT ALL THAT APPLY) Assess client's:

Correct Answer is ["A","B","C","E"]

Explanation

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