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 A
Explanation
Choice A rationale:
Identifying possible precipitating factors related to the infections is the first step in addressing the issue of increased catheter infections. Understanding the potential causes, such as poor catheter insertion techniques, inadequate hygiene practices, or contaminated equipment, can help the nurse pinpoint the areas that need improvement. By identifying these factors, the nurse can implement targeted interventions to prevent future infections.
Choice B rationale:
Meeting with providers to discuss measures to decrease infections is a valid step, but it should come after identifying the specific factors contributing to the infections. Without a clear understanding of the root causes, the discussion with providers may lack focus and may not lead to effective solutions.
Choice C rationale:
Revising the current policy for catheter care can be considered after identifying the precipitating factors. Policy revision should be based on evidence-based practices and a thorough understanding of the issues contributing to the infections. Simply revising the policy without addressing the underlying causes may not lead to significant improvements.
Choice D rationale:
Scheduling nursing staff training for infection control procedures is an important step in preventing infections, but it should also follow the identification of specific issues related to the catheter infections. Training programs can be tailored to address the identified problems and provide targeted education to the staff members involved.
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.
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