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. Use only written communication whenever possible to minimize the client's frustration.Written communication can be helpful in some situations, but it should not be the primary mode of communication for clients with moderate hearing loss unless necessary.

B. Minimize background noises such as the television and ensure that lighting is adequate to see the nurse's face.Reducing background noise and ensuring proper lighting are critical strategies for effective communication with individuals with hearing loss. These steps make it easier for the resident to hear and understand, and they also allow the resident to use visual cues, such as lip-reading, to enhance communication.

C. Use vocabulary and concepts that are as simple as possible.
While simplifying vocabulary may help some individuals, it is not necessary or beneficial for all residents with hearing loss. This could come across as condescending unless it aligns with the client’s cognitive ability.

D. Repeat each direction or question multiple times, even if the client states he heard and understands the directions: Repeating unnecessarily can be frustrating and counterproductive for the client. It is more effective to ensure the initial communication is clear and check for understanding without excessive repetition unless the resident indicates they need clarification.

A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. B. Keep the patient standing and call for assistance to continue to move with the help of another nurse. C. Have the patient sit down on the bed and dangle her feet for a few seconds and then attempt the move again. D. Continue to walk the patient to the chair and if the patient faints, lower them gently to the floor.

Correct Answer is A

Explanation

The correct answer is choice A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.

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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

A resident of a long-term care facility has moderate hearing loss and is hard of hearing. When communicating with this resident, which of the following would be the best initial technique?

Correct Answer is B

Explanation

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

Correct Answer is A

Explanation

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