A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

Obtain bottles of warm, sterile 0.9% sodium chloride solution.

Apply a firm pressure dressing across the client's abdomen.

Attempt to reinsert the protruding viscera.

Place the client in left lateral recumbent position.

Answer and Explanation

The Correct Answer is A

A. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Evisceration requires immediate coverage of the exposed organs with sterile, saline-moistened dressings to prevent drying and infection. Using warm saline helps maintain tissue viability and minimizes damage.

B. Apply a firm pressure dressing across the client's abdomen: A firm pressure dressing is inappropriate, as it could cause further damage to the eviscerated organs and increase intra-abdominal pressure, leading to ischemia or perforation.

C. Attempt to reinsert the protruding viscera: Reinserting the eviscerated organs is contraindicated due to the high risk of contamination, trauma, and further complications. The nurse should instead protect the organs with moist dressings and prepare the client for emergency surgery.

D. Place the client in left lateral recumbent position: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce tension on the abdominal wound and prevent further protrusion of organs. A left lateral recumbent position does not provide the same benefit.

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Correct Answer is A

Explanation

A. Xerostomia: Radiation therapy to the head and neck often damages the salivary glands, leading to xerostomia, or dry mouth. This can cause difficulty in speaking, swallowing, and an increased risk of oral infections. Providing oral hydration and saliva substitutes can help manage this side effect.

B. Epistaxis: While radiation therapy can cause mucosal irritation, epistaxis (nosebleeds) is not a common side effect. Epistaxis is more frequently associated with conditions such as nasal trauma, clotting disorders, or chemotherapy-induced thrombocytopenia rather than localized radiation therapy.

C. Tinnitus: Radiation therapy does not typically cause tinnitus, which is more commonly linked to ototoxic medications, prolonged noise exposure, or inner ear disorders. If a tumor or treatment affects the auditory structures, hearing-related symptoms may occur but are not a primary radiation side effect.

D. Diplopia: Double vision is not a usual complication of radiation therapy to the head and neck. Diplopia is more commonly associated with neurological conditions, cranial nerve dysfunction, or ocular disorders rather than radiation-induced effects on surrounding tissues.

A. Increased body hair B. Decreased blood urea nitrogen level C. Hyperpigmentation of the skin D. Hypocalcemia

Correct Answer is C

Explanation

A. Increased body hair: Adrenal insufficiency leads to decreased androgen production, which may cause hair thinning rather than increased body hair. Hypertrichosis (excessive hair growth) is not a typical finding in adrenal insufficiency.

B. Decreased blood urea nitrogen level: Adrenal insufficiency is often associated with dehydration due to aldosterone deficiency, leading to reduced sodium retention and increased fluid loss. This can result in elevated blood urea nitrogen (BUN) levels rather than a decrease.

C. Hyperpigmentation of the skin: Increased melanocyte-stimulating hormone (MSH) activity, triggered by elevated adrenocorticotropic hormone (ACTH) levels, causes darkening of the skin, especially in sun-exposed areas, skin folds, and mucous membranes. This is a hallmark feature of primary adrenal insufficiency (Addison’s disease).

D. Hypocalcemia: Adrenal insufficiency is more commonly associated with hypercalcemia rather than hypocalcemia. Decreased cortisol levels can lead to reduced renal calcium excretion, contributing to elevated serum calcium levels.

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A charge nurse is called to a client's room after a staff nurse reports a client has had a wound evisceration. Which of the following actions should the charge nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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