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 choice c. Swelling of the face.
Choice A rationale:
Urinary frequency is a common symptom during pregnancy, especially in the first and third trimesters, due to hormonal changes and the growing uterus pressing on the bladder. It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination, which could indicate a urinary tract infection.
Choice B rationale:
Bleeding gums are also common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding. This condition, known as pregnancy gingivitis, is usually not serious but should be managed with good oral hygiene.
Choice C rationale:
Swelling of the face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs, often the kidneys. Preeclampsia typically occurs after 20 weeks of gestation but can develop earlier. It requires immediate medical attention to prevent complications for both the mother and the baby.
Choice D rationale:
Faintness upon rising, or orthostatic hypotension, is relatively common during pregnancy due to changes in blood circulation. It can usually be managed by rising slowly from a sitting or lying position. However, if fainting is frequent or severe, it should be discussed with a healthcare provider to rule out other underlying conditions.
Correct Answer is A
Explanation
Choice A rationale:
"Uneven shoulder and pelvic heights." This is the correct answer. Uneven shoulder and pelvic heights, along with an asymmetrical appearance of the spine when viewed from the back, are clinical manifestations of scoliosis. Scoliosis is a sideways curvature of the spine that often develops during the growth spurt before puberty. Screening for scoliosis typically involves assessing the alignment of the spine and looking for these asymmetries.
Choice B rationale:
Exaggerated curvature of the sacrum is not a typical sign of scoliosis. Scoliosis primarily affects the upper back and can cause a side-to-side curvature of the spine, not the sacrum.
Choice C rationale:
Limited range-of-motion of the hips is not a specific indicator of scoliosis. Restricted hip movement might suggest other musculoskeletal issues but is not directly related to scoliosis.
Choice D rationale:
Mild pain in the hip region is not a characteristic symptom of scoliosis. While scoliosis can cause discomfort, it typically manifests as back pain, not specifically in the hip region. Pain symptoms can vary widely among individuals and might not be present in all cases of scoliosis.
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