A nurse is 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 dry sterile dressing.
Cover the wound with a transparent dressing.
The Correct Answer is A
Explanation: Evisceration is a surgical emergency that occurs when the abdominal contents protrude through the incision site. The nurse should instruct the client to lie supine with his knees flexed to reduce tension on the wound and prevent further damage.
The nurse should also cover the wound with a moist sterile dressing and notify the surgeon immediately. Positioning the client in semi-Fowler's position, covering the wound with a dry sterile dressing, or covering the wound with a transparent dressing are not appropriate actions for evisceration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Increased urinary output indicates that furosemide, a loop diuretic, is effective in reducing fluid retention and edema in clients with heart failure. The other findings are not indicative of furosemide effectiveness and may suggest adverse effects or complications. Decreased BUN level may indicate overhydration or liver dysfunction. Decreased hemoglobin level may indicate anemia or bleeding. Increased weight of 0.91 kg (2 lb) may indicate fluid overload or worsening heart failure.
Correct Answer is B
Explanation
The correct answer is choiceb. Obtain a CBC with differential.
Choice A rationale:
Drawing blood specimens for culture and sensitivity is not typically required before a cardiac catheterization unless there is a specific concern about infection.
Choice B rationale:
Obtaining a CBC with differential is important to assess the client’s overall health and detect any potential issues such as anemia or infection that could complicate the procedure.
Choice C rationale:
Transporting the client to radiology for a CT scan is not a standard pre-procedure task for cardiac catheterization. This might be necessary if there are specific indications, but it is not routine.
Choice D rationale:
Administering nitroglycerin 0.4 mg SL 30 minutes before the procedure is not a standard practice for preparing a client for cardiac catheterization.Nitroglycerin is typically used to manage chest pain or angina, not as a pre-procedure medication.
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