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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.
Correct Answer is C
Explanation
Choice A rationale:
Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.
Choice B rationale:
Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.
Choice C rationale:
Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.
Choice D rationale:
Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.
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