Upon assessment, a nurse suspects that a patient with a recent abdominal surgery is at risk of evisceration. Which of the following factors most strongly contributes to this risk?
The patient has a high-protein diet.
Patient is ambulating frequently post-surgery.
The patient has a history of chronic coughing and sneezing.
Patient is on immunosuppressant therapy.
The Correct Answer is C
A. The patient has a high-protein diet: A high-protein diet promotes healing, which would decrease the risk of wound separation.
B. Patient is ambulating frequently post-surgery: Frequent, gentle ambulation improves circulation and general strength, which helps recovery and reduces complications like infection and DVT.
C. The patient has a history of chronic coughing and sneezing: This is the most strongly contributing factor. Any activity that suddenly and dramatically increases intra-abdominal pressure (like severe coughing, vomiting, straining, or sneezing) can place extreme tension on a healing surgical incision, leading to separation (dehiscence) and potentially organ protrusion (evisceration).
D. Patient is on immunosuppressant therapy: This is a factor that impairs healing and increases infection risk, but it does not directly cause the mechanical failure of the incision, which is the immediate cause of evisceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Apply talcum powder to areas at risk for breakdown:Talcum powder can cake or clump when mixed with moisture, which can act as an abrasive, causing friction and irritation that leads to skin breakdown.
B. Encourage the client to drink more fluids:This is an important intervention to maintain tissue hydration and perfusion, but it is not the most crucial direct measure to prevent mechanical injury on bony prominences.
C. Use pillows and cushions to support and position the client:Utilizing pillows, wedges, and specialty cushions is critical for proper alignment, redistribution of pressure, and ensuring that bony prominences (like the heels, sacrum, and trochanters) are floating or supported to eliminate skin-to-skin contact and relieve external pressure.
D. Perform a complete bed bath daily:This is a routine personal hygiene measure. While cleanliness is important, it is less crucial than pressure redistribution in the prevention of pressure injuries on bony prominences.
Correct Answer is D
Explanation
A. Apply alcohol-based lotion to dry out the site: Alcohol is cytotoxic and irritating and would likely worsen the irritation and could harm the healing abrasion.
B. Apply a thick, occlusive dressing to prevent exposure: An occlusive dressing would trap the increased drainage and moisture against the skin, which would lead to maceration and worsening of the irritation.
C. Increase the frequency of bathing to keep the area clean: While cleanliness is important, excessive bathing can dry out the skin and does not directly address the localized issue beneath the bandage.
D. Change the bandage and clean the area with an antiseptic:The nurse must remove the soiled bandage to visualize and assess the wound and surrounding skin (for signs of infection, maceration, or inflammation). The area should then be gently cleansed (with saline or an appropriate wound cleanser) and a new, appropriate dressing applied to manage the increased drainage.
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