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

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.

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Correct Answer is D

Explanation

Answer: D. Elevated lipase

Rationale: Pancreatitis is an inflammation of the pancreas that causes pancreatic enzymes to leak into the bloodstream and damage surrounding tissues. Lipase is one of these enzymes that is produced by the pancreas to digest fats. An elevated lipase level indicates pancreatic injury and is a diagnostic marker for acute pancreatitis. The other laboratory results are not specific to pancreatitis and could be caused by other conditions.

A. Tie the gown with the gloves on. B. Tuck the glove cuffs under the gown sleeves. C. Apply the gown before the gloves. D. Push the gown sleeves up to the elbows.

Correct Answer is C

Explanation

The correct answer is B.

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves. The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist. The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

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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

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