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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Iron is essential for healthy blood, but it is not specifically associated with preventing neural tube defects. Iron supplementation is crucial during pregnancy to prevent iron-deficiency anemia.
Choice B rationale:
Calcium is essential for bone health, but it is not directly related to preventing neural tube defects. Adequate calcium intake is vital, especially during adolescence and pregnancy, to support bone development and maintenance.
Choice C rationale:
"Folate." This is the correct answer. Folate, also known as vitamin B9, is crucial for preventing neural tube defects. Adequate folate intake, especially before and during early pregnancy, can significantly reduce the risk of neural tube defects in newborns. The normal recommended dietary allowance (RDA) for folate is 400 micrograms per day for adults.
Choice D rationale:
Zinc is a mineral important for immune function and wound healing but is not specifically associated with preventing neural tube defects. Adequate zinc intake is essential for overall health, but it is not a primary nutrient targeted for neural tube defect prevention.
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Checking the client’s condition after the procedure involves assessment, which is a critical component of the nursing process. This task requires clinical judgment and knowledge of potential complications, which are responsibilities that cannot be delegated to assistive personnel.
Choice B reason: Assisting with ambulation is a task that can be safely delegated to assistive personnel. It is a basic care task that does not require clinical judgment and can be performed under the supervision of a nurse.
Choice C reason: Witnessing a client’s signature on the consent for the procedure is a legal and ethical responsibility that involves ensuring the client understands the procedure and is giving informed consent. This task requires a level of professional accountability that is beyond the scope of assistive personnel.
Choice D reason: Administering medication, such as atropine 30 minutes before the procedure, is a nursing intervention that requires knowledge of pharmacology and the ability to monitor for adverse effects. This is not within the scope of practice for assistive personnel and must be performed by licensed nursing staff.
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