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
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Correct Answer is D
Explanation
The correct answer is D.
Reduced fat in the stools. Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas, which are lacking in most people with cystic fibrosis due to excess mucus production that clogs the pancreatic ducts. By taking pancrelipase, the child can improve their digestion of food and absorb more nutrients, especially fat and fat-soluble vitamins. This will result in reduced fat in the stools, which is a sign of pancreatic insufficiency.
Correct Answer is D
Explanation
The correct answer is D. Muscle pain is a sign of rhabdomyolysis, a rare but serious condition that can occur with statin use and can lead to kidney failure. The nurse should instruct the client to report any muscle pain, weakness, or tenderness to the provider immediately.
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