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
The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Information regarding client health can be e-mailed if encrypted. The nurse should follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines to protect client privacy and confidentiality. According to HIPAA, health information can be transmitted electronically if it is encrypted or otherwise secured.
Unwanted printed health information should be shredded or disposed of in a secure bin, not a trash can. Members of a healthcare team should not share a computer password or leave a computer unattended when accessing client information. A client has the right to access his own medical records and request amendments or corrections.
Correct Answer is D
Explanation
The correct answer is D.
Social worker. The rationale is that a social worker can help the client access community resources and transportation services that can facilitate their attendance to follow-up appointments. The social worker can also assess and address any psychosocial barriers that may affect the client's adherence to treatment.
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