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

Choice A rationale:
A warm left leg is a normal finding and does not require immediate intervention. Warmth indicates adequate circulation to the limb.
Choice B rationale:
A pedal pulse strength of 2 in the left leg indicates diminished pulse but does not require immediate intervention. The nurse should continue to monitor the pulse and report any significant changes to the healthcare provider.
Choice C rationale:
The client's report of pain in the foot of the left leg is an expected finding due to the fractured left femur. Pain is a subjective symptom, and the nurse should address the client's pain appropriately but not intervene immediately based on this finding.
Choice D rationale:
This is the correct choice. A capillary refill time of 3 seconds in the left foot suggests impaired circulation, which could be indicative of compartment syndrome or other circulation-related issues. The nurse should intervene immediately by notifying the healthcare provider to prevent further complications.

A. The nurse files an incident report regarding a medication error. B. The nurse provides wound care to a client at the time promised to the client. C. The nurse declines to inform a client's neighbor about the client's prognosis. D. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services.

Correct Answer is C

Explanation

Answer: C. The nurse declines to inform a client's neighbor about the client's prognosis.

Rationale:

A) The nurse files an incident report regarding a medication error:

Filing an incident report is crucial for patient safety and quality improvement but primarily serves organizational processes. It helps identify and address systemic issues to prevent future errors, but it is not a direct act of advocacy for the individual client.

B) The nurse provides wound care to a client at the time promised to the client:

Providing timely care demonstrates reliability and respect for the client's needs, which is an important aspect of nursing care. However, this action alone does not constitute advocacy, as it is more about fulfilling professional responsibilities and maintaining trust.

C) The nurse declines to inform a client's neighbor about the client's prognosis:

Declining to share confidential information with a neighbor is a direct act of advocacy. It protects the client's right to privacy and confidentiality, ensuring that sensitive health information is disclosed only to authorized individuals. Upholding these ethical standards is a fundamental aspect of advocating for the client's rights and dignity.

D) The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:

Referring a client to palliative care is an important aspect of providing holistic and compassionate care, but it is a broader action related to care coordination rather than a specific advocacy action in the context of maintaining client confidentiality and rights.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a neurovascular assessment on a client who has a fractured left femur. For which of the following findings should the nurse intervene immediately?

Correct Answer is D

Explanation

A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?

Correct Answer is C

Explanation

A nurse is teaching an older adult client who has osteoporosis about ways to promote musculoskeletal health. Which of the following instructions should the nurse include?

A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?

A nurse is assessing a client's ability to adapt to a new colostomy. Which of the following client statements indicates to the nurse the client is adapting?

A nurse is preparing to give a bed bath to a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse plan to take?

A nurse is teaching a client who has schizophrenia a new prescription for lurasidone. Which of the following information should the nurse include in the teaching?(Select all that apply.).

A nurse is completing discharge teaching with a client who has a new prescription for enoxaparin to treat unstable angina. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who had moderate sedation during a procedure. The client's airway is obstructing, and they have an oxygen saturation of 90%. Which of the following interventions is the first action the nurse should take?

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?