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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.

Choice B rationale:

Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.

Choice C rationale:

Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.

Choice D rationale:

Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.

A. A client who has epidural analgesia and weakness in the lower extremities. B. A client who has diabetes mellitus and an HbA1c of 6.89%. C. A client who has a hip fracture and a new onset of tachypnea. D. A client who has sinus arrhythmia and is receiving cardiac monitoring.

Correct Answer is C

Explanation

Choice A rationale:

The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.

Choice B rationale:

The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.

Choice C rationale:

The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.

Choice D rationale:

The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations.Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is receiving change-of-shift report for a group of clients.Which of the following clients should the nurse plan to assess first?

Correct Answer is C

Explanation

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk.After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?

A nurse in an acute care mental health facility is placing a client in seclusion and restraints.Which of the following actions should the nurse plan to take?

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

A charge nurse is concerned about a recent increase in facility-acquired catheter infections.Which of the following actions should the nurse take first?

A nurse is admitting a client to a medical-surgical unit.When performing medication reconciliation for the client, which of the following actions should the nurse take?