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 A

Explanation

The correct answer is choice A, tertiary.

Tertiary prevention aims to improve quality of life and reduce the negative impact of a chronic illness or disability, such as helping the man regain lost function after a stroke. Occupational therapy is a common intervention in tertiary prevention, as it focuses on helping patients adapt to their limitations and develop compensatory strategies to perform daily activities.

Primary prevention aims to prevent a disease or injury before it occurs, such as immunizations or health education to prevent stroke risk factors. Secondary prevention aims to detect and treat a disease in its early stages to prevent complications, such as screening for high blood pressure or high cholesterol levels. Quaternary prevention aims to reduce the harm caused by unnecessary or excessive healthcare interventions, such as avoiding overprescribing medications.

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. 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. 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. 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.

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).

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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

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