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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.
B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.
C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.
D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.
Correct Answer is D
Explanation
The correct answer is choice D, alternating waves of air stimulate breathing. CPAP works by delivering a continuous stream of pressurized air through a mask, which is worn over the nose or nose and mouth while sleeping. This air pressure acts like a splint, holding the airway open and preventing it from collapsing during sleep. The alternating waves of air delivered by the CPAP machine help stimulate breathing, keeping the airway open and reducing the number of breathing pauses that occur during sleep. CPAP is a highly effective treatment for obstructive sleep apnea, a condition in which the airway becomes blocked during sleep, leading to breathing pauses and interrupted sleep. By keeping the airway open and stimulating breathing, CPAP helps to improve sleep quality, reduce daytime sleepiness, and improve overall health outcomes in people with sleep apnea.
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