A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way.”. The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.).

Place the client in a low Fowler's position with the knees bent.

Cover the client's wound with a sterile saline-soaked dressing.

Notify the surgeon about the finding.

Prepare the client for transfer to surgery.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.

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Correct Answer is D

Explanation

Answer: D. Contact the provider who will be performing the procedure.

Rationale:

A) Provide teaching about the surgical procedure for the client:

While nurses play an essential role in patient education, it is the responsibility of the healthcare provider performing the procedure to ensure the patient fully understands the details, risks, and benefits. Nurses can clarify information but should not provide the initial comprehensive explanation of the procedure.

B) Instruct the client's spouse to sign the consent form:

The client is the one who needs to provide informed consent, not the spouse, unless the client is legally unable to do so. In such cases, legal documentation, such as a power of attorney, is required. Instructing the spouse to sign without proper authorization is inappropriate and potentially legally problematic.

C) Read the consent form to the client using words the client will understand:

While simplifying the language of the consent form can help, it is not sufficient if the client does not fully understand the procedure. Full understanding requires a detailed discussion about the procedure, risks, benefits, and alternatives, which should be done by the provider performing the procedure.

D) Contact the provider who will be performing the procedure:

The provider performing the procedure has the responsibility to ensure the client understands all aspects of the surgery. Contacting the provider to provide a thorough explanation ensures that the client receives accurate and complete information, allowing for truly informed consent.

A. Schedule the client for the last surgery of the day. B. Place monitoring cords and tubes in a stockinette. C. Choose rubber injection ports for fluid administration. D. Have phenytoin IV readily available.

Correct Answer is B

Explanation

Choice A rationale:

Scheduling the client for the last surgery of the day is not directly related to the client's latex allergy. Proper planning for surgery in a latex-allergic client involves addressing potential exposures to latex-containing products and minimizing the risk of allergic reactions.

Choice B rationale:

Placing monitoring cords and tubes in a stockinette can help create a barrier between the client's skin and the latex-containing products. This measure helps reduce the risk of direct contact with latex, which could trigger an allergic reaction in a latex-sensitive individual.

Choice C rationale:

Choosing rubber injection ports for fluid administration is not appropriate for a client with a latex allergy. Rubber products often contain latex, which can lead to an allergic reaction in susceptible individuals.

Choice D rationale:

Having phenytoin IV readily available is not directly relevant to a client with a latex allergy. Phenytoin is an antiepileptic medication and should be available for clients who require it, but it does not address the specific concern of latex exposure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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