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 B

Explanation

A. Contact your pharmacy to inquire about a different medication: Pharmacies may offer generic alternatives, but they cannot change a prescription without provider authorization. A social worker can explore financial assistance programs, which is a more comprehensive solution.

B. I can arrange for a social worker to talk with you before you leave: Social workers assist clients in finding resources such as medication assistance programs, prescription discount plans, or community aid. This ensures the client can access their medication without financial strain.

C. You should ask your provider to prescribe a cheaper medication: While discussing cost-effective alternatives with the provider is an option, it does not directly address the client’s financial concerns. A social worker can provide broader support beyond just switching medications.

D. I can contact the occupational therapist to schedule a home visit: Occupational therapy focuses on improving daily function and independence. It does not address financial concerns related to medication affordability, making this option inappropriate for the situation.

A. Instructions on how to take metoprolol B. How to check blood glucose at home C. Check feet weekly on the same day each week. D. Perform 100 min of physical activity per week. E. Weight loss tips F. Manifestations of hyperglycemia and hypoglycaemia

Correct Answer is ["B","C","F"]

Explanation

How to check blood glucose at home: Since the client has a blood glucose level of 250 mg/dL, which is elevated, it is essential to teach the client how to monitor their blood glucose at home. Self-monitoring will help the client manage their diabetes effectively and recognize when to seek medical attention.
Check feet weekly on the same day each week: Given the presence of an open wound on the client's foot, it is important to emphasize proper foot care and regular inspection for any sores or changes. Checking feet weekly can help prevent complications such as infections or ulcers, especially in clients with diabetes.
Manifestations of hyperglycemia and hypoglycemia: Educating the client about the signs and symptoms of both hyperglycemia (e.g., increased thirst, frequent urination, fatigue) and hypoglycemia (e.g., shakiness, sweating, confusion) is crucial for safety. This knowledge empowers the client to take appropriate action when they experience these symptoms.

Instructions on how to take metoprolol: There is no indication in the provided information that the client is prescribed metoprolol. While teaching about medications is important, it should be based on the specific medications the client is taking.
Perform 100 min of physical activity per week: While physical activity is beneficial for overall health and can help manage diabetes, the emphasis should be on tailoring an exercise plan to the client's current health status and capabilities. A more individualized approach should be taken, and it may not be the priority at this stage due to the client's current condition.
Weight loss tips: While the client has reported recent weight loss, it is unclear whether this is intentional or a result of uncontrolled diabetes. Teaching weight loss tips may not be appropriate until the client’s diabetes is better managed and their nutritional needs are assessed more thoroughly.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020. Which of the following should the nurse plan to include when providing teaching for the client? Select all that apply.

Correct Answer is ["B","C","F"]

Explanation

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