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 C

Explanation

A. Flushed cheeks: Tuberculosis typically presents with systemic symptoms such as fever, night sweats, and weight loss rather than flushed cheeks. Flushing is more commonly associated with fever spikes in other infections or conditions like menopause.

B. Severe headaches: Tuberculosis can cause headaches if it leads to tuberculous meningitis, but this is not a common initial symptom of pulmonary tuberculosis. Headaches are not a hallmark feature of active TB infection.

C. Low-grade fever: A persistent low-grade fever, particularly in the afternoon or evening, is a common symptom of tuberculosis. It is often accompanied by night sweats and weight loss due to the chronic inflammatory response.

D. Dry cough: The cough associated with tuberculosis is usually productive with purulent or blood-tinged sputum rather than dry. The infection causes lung tissue destruction, leading to a persistent cough with mucus production.

A. Place the client in a negative pressure room. B. Dispose of the radioactive source in the client's trash can. C. Limit each visitor to 1 hr per day. D. Use long-handled forceps if the radioactive source is dislodged.

Correct Answer is D

Explanation

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne precautions, such as tuberculosis, but are not required for internal brachytherapy. Clients receiving internal radiation require a private room with appropriate shielding to limit radiation exposure.

B. Dispose of the radioactive source in the client's trash can: Radioactive sources should never be discarded in regular trash. If dislodged, the source must be handled properly using protective equipment and disposed of in a designated lead container to prevent radiation exposure.

C. Limit each visitor to 1 hr per day: Visitors should be limited to 30 minutes per day and should maintain a distance of at least 6 feet from the client. This minimizes radiation exposure to family members and healthcare providers.

D. Use long-handled forceps if the radioactive source is dislodged: If the internal radiation source becomes dislodged, it should never be touched directly. Long-handled forceps should be used to carefully place the source in a lead-lined container to protect against radiation exposure.

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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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