Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

Pour sterile hydrogen peroxide into the abdominal cavity and pack it with gauze.

Pour normal saline on the area and gently place organs back into the cavity.

Attempt to close the wound area with reinforced adhesive skin closures.

Cover the wound area with sterile gauze moistened with sterile 0.9% normal saline.

Answer and Explanation

The Correct Answer is D

Upon discovering that the client's abdominal wound has been eviscerated, the nurse should immediately cover the wound area with sterile gauze moistened with sterile 0.9% normal saline. This will help to protect the exposed organs and prevent them from becoming dry or exposed to contaminants. Pouring hydrogen peroxide into the abdominal cavity can cause further damage to the exposed organs and is not recommended. Similarly, normal saline should be gently poured on the area to moisten it, but organs should not be placed back into the cavity as this can cause further injury. Attempting to close the wound area with reinforced adhesive skin closures is also not appropriate as the wound needs to be assessed and repaired by a healthcare provider. The nurse should call the healthcare provider and provide ongoing assessment and support to the client while waiting for further interventions.

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Correct Answer is B

Explanation

A. Skin was pink, warm, dry, and intact. Capillary refill was less than 5 seconds in all fingers. Radial pulses were +4 and equal bilaterally. Grips were strong 10 out of 10 and equal bilaterally:
Incorrect. Capillary refill should be less than 2-3 seconds for normal findings; less than 5 seconds would be too long and could indicate poor perfusion. Radial pulses graded +4 are not typical and suggest a bounding pulse, which could indicate an abnormal condition. Grips graded 10/10 is not the standard grading system; typically, grips are graded out of 5.

B. Skin was pink, warm, dry, and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were +2 and equal bilaterally. Grips were strong 5/5 and equal bilaterally:
Correct. This option uses proper terminology. Capillary refill of less than 3 seconds is normal, radial pulses graded +2 are normal, and grips are appropriately graded on a 5-point scale, with 5/5 being the normal strength.

C. Skin was pink, warm, dry, and intact. Capillary refill was more than 3 seconds in all fingers. Radial pulses were 1 and equal. Grips were strong 4/4 and symmetrical:
Incorrect. Capillary refill of more than 3 seconds indicates delayed perfusion, which is abnormal. Radial pulses graded 1 indicate a weak pulse, which is not within normal limits. Additionally, grips are usually graded out of 5, not 4.

D. Skin was warm and dry and intact. Capillary refill was less than 3 seconds in all fingers. Radial pulses were 3. Grips were strong and equal:
Incorrect. While some aspects are correct (capillary refill), the pulse grading system is incomplete here. Radial pulses should be recorded as +1 to +4, and +3 would indicate a stronger-than-normal pulse, which is not typical for normal findings. Grip strength is not fully documented here either, as it should include a scale (e.g., 5/5).

A. Air pads wrap around your arms and are connected to a vacuum which improves blood flow. B. These are elastic stockings that apply pressure to the legs and increase the velocity of blood flow. C. SCDs are only worn during amputation to provide support and prevent pooling of blood in the legs. D. The device fills with air that applies intermittent or sequential pressure to the legs to enhance blood flow and venous return.

Correct Answer is D

Explanation

The correct answer is choice D. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.

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Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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