A nurse is assisting in caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Instruct the client to lie supine with his knees flexed.

Position the client in semi-Fowler's position.

Cover the wound with a transparent dressing.

Cover the wound with a dry sterile dressing.

Answer and Explanation

The Correct Answer is A

Evisceration is a surgical emergency in which abdominal organs protrude through a dehisced incision. It most commonly occurs after abdominal surgery due to increased intra-abdominal pressure or wound failure. Immediate nursing actions focus on protecting exposed organs, preventing further injury, and preparing for surgical intervention. Positioning is critical to reduce tension on the incision and minimize additional protrusion of abdominal contents.

Rationale:
A. Placing the client in a supine position with knees flexed helps reduce strain on the abdominal incision and decreases tension on the exposed organs. Flexing the knees relaxes abdominal muscles, minimizing further evisceration. This position is the immediate priority to stabilize the situation while awaiting surgical intervention.

B. Semi-Fowler’s position increases pressure on the abdominal cavity due to gravitational force and may worsen organ protrusion. This position places additional strain on the surgical incision and is therefore contraindicated in cases of evisceration. Immediate reduction of abdominal tension is the priority.

C. Covering the wound with a transparent dressing is not appropriate because it does not adequately protect exposed abdominal organs. Evisceration requires sterile, moist, and bulky dressings to prevent tissue drying and contamination. Transparent dressings do not provide sufficient coverage or moisture maintenance.

D. Covering the wound with a dry sterile dressing is also incorrect because exposed abdominal organs must be kept moist to prevent tissue desiccation and necrosis. Dry dressings can cause damage to protruding tissues. Instead, sterile gauze soaked in sterile saline is typically used to cover the site.

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Correct Answer is A

Explanation

Advance directives are legal documents that allow clients to communicate their healthcare preferences in advance, in case they become unable to make decisions in the future. These may include a living will and designation of a healthcare proxy or durable power of attorney for healthcare. They ensure that the client’s autonomy and treatment wishes are respected during illness or surgical procedures. Nurses play an important role in educating clients about their purpose and encouraging informed decision-making.

Rationale:
A. Advance directives protect a client’s right to make their own healthcare decisions by clearly documenting their wishes regarding treatment and end-of-life care. They ensure that healthcare providers and family members follow the client’s preferences if the client becomes incapacitated. This statement accurately reflects the purpose of advance directives and supports client autonomy.

B. Advance directives do not require approval by a lawyer to be valid in most settings. While legal consultation may help with preparation, many advance directives can be completed using standardized forms and require only proper signing and witnessing. Therefore, this statement is incorrect and may create unnecessary barriers to completion.

C. Advance directives are not limited to clients with life-threatening conditions. Any competent adult can complete them at any time, regardless of current health status. They are intended for future planning, not only for those who are critically ill.

D. Advance directives are not the same as a consent form for healthcare treatment. Consent forms are used to authorize specific procedures at a given time, while advance directives outline broader preferences for future care decisions. They serve different legal and clinical purposes.

A. Client reports sharp pain B. Astigmatism C. Loss of central vision D. Nystagmus

Correct Answer is C

Explanation

Macular degeneration is a progressive eye disorder that affects the macula, the central portion of the retina responsible for sharp, detailed vision. It is a leading cause of vision loss in older adults and primarily impacts the ability to see fine details needed for reading, driving, and recognizing faces. The condition typically progresses slowly and is not associated with pain. Nurses focus on identifying characteristic visual changes to support early intervention and safety planning.

Rationale:
A. Sharp pain is not associated with macular degeneration because the condition affects the retina, which lacks pain receptors. Patients typically do not experience discomfort; instead, they notice gradual visual changes. Pain would suggest other ocular conditions such as acute glaucoma or infection.

B. Astigmatism is a refractive error caused by an irregular curvature of the cornea or lens, leading to blurred or distorted vision at all distances. It is unrelated to macular degeneration, which specifically affects central retinal function rather than corneal shape.

C. Loss of central vision is the hallmark finding in macular degeneration due to degeneration of the macula. Patients often report difficulty reading, recognizing faces, or seeing fine details while peripheral vision remains intact. This central vision loss significantly impacts daily functioning.

D. Nystagmus is characterized by involuntary rhythmic eye movements and is typically associated with neurological disorders, vestibular dysfunction, or congenital conditions. It is not a characteristic finding of macular degeneration, which primarily affects visual acuity rather than eye movement control.

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A nurse is assisting in caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

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