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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Administering 2 ounces of water to the newborn prior to the test is not a standard practice for newborn genetic screening. Newborns are typically screened for genetic disorders through a blood test, not by giving them water.

Choice B rationale:

This statement is incorrect. Newborn genetic screening is usually performed shortly after birth, not at 2 months old. Early screening allows for the early detection of certain genetic disorders, enabling timely interventions if needed.

Choice D rationale:

Drawing blood from the newborn's inner elbow is not specific guidance related to newborn genetic screening. Blood can be drawn from various sites, and healthcare providers choose the most appropriate site based on the newborn's condition and the required tests.

A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.

Correct Answer is D

Explanation

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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