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
Answer: B. Loss of taste
Rationale: External radiation for throat cancer can damage the taste buds and cause loss of taste or altered taste sensation. This can affect the client's nutritional intake and quality of life. The other options are not expected findings of external radiation for throat cancer and could be caused by other factors.
Correct Answer is B
Explanation
The correct answer is B. "You will need to urinate before the procedure." The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage .
To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .
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