A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Prepare the client to return to the operating room.
Obtain a sample of the drainage to send to the lab.
Bring additional sterile dressing supplies to the room.
Auscultate the abdomen for bowel sound activity.
The Correct Answer is A
A. Prepare the client to return to the operating room:
This is the correct and immediate priority. Evisceration, where internal organs protrude through the surgical incision, is a surgical emergency. Returning the client to the operating room is necessary to assess the extent of the complication, address the wound dehiscence, and protect the exposed organs. This intervention aims to prevent further complications and provide necessary surgical interventions.
B. Obtain a sample of the drainage to send to the lab:
While obtaining samples for laboratory analysis can be important for infection control, in the context of a client with evisceration, the primary concern is the surgical emergency. The priority is to address the wound complication by returning to the operating room rather than focusing on laboratory analysis at this immediate moment.
C. Bring additional sterile dressing supplies to the room:
While bringing additional supplies may be necessary, the priority in this situation is to prepare for the client's return to the operating room. Once the client is in a controlled surgical environment, additional dressing changes and wound care can be performed as needed.
D. Auscultate the abdomen for bowel sound activity:
While monitoring bowel sounds is a routine nursing assessment, in the context of evisceration, the immediate concern is the exposure of internal organs and the risk of infection. Preparing for the operating room takes precedence over routine assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Move the client to a private room, keep the door closed, and initiate droplet precautions:
This is the correct answer. Given the client's symptoms and potential exposure to COVID-19, it is important to take infection control measures. Placing the client in a private room, keeping the door closed, and initiating droplet precautions help prevent the potential spread of the virus.
B. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:
Antiviral medications are typically prescribed based on confirmed COVID-19 test results and the severity of symptoms. Starting an intravenous infusion at this stage, before test results are available, is premature and not indicated.
C. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with the patient:
While it is important for family members to monitor for symptoms, the immediate concern is the isolation and testing of the symptomatic client. Contact tracing may follow, but infection control measures for the client are the priority.
D. Assist the client to recall everyone possibly exposed since onset of symptoms:
While contact tracing is important, the immediate action is to isolate the client and initiate precautions. Contact tracing can be done as part of a broader public health response but is not the initial step.
Correct Answer is D
Explanation
A. Guidelines for oxygen use:
While guidelines for oxygen use are important, addressing the root cause of the respiratory condition, which includes smoking cessation, is crucial for long-term management.
B. Methods for weight loss:
Obesity can contribute to respiratory issues, but in the immediate context of emphysema exacerbation and the need for oxygen therapy, smoking cessation is a more urgent concern.
C. Approaches to conserve energy:
Conserving energy is important for clients with emphysema, but addressing the impact of smoking on respiratory function is a more immediate priority.
D. Strategies for smoking cessation.
Smoking is a major contributor to the progression of emphysema and exacerbation of respiratory symptoms. Addressing smoking cessation is crucial in improving the client's respiratory function and overall health. Continuing to smoke can exacerbate emphysema and compromise the effectiveness of other interventions, including oxygen therapy.
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