A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?

Prepare the client for surgery.

Cover the protrusion with a dressing soaked in 0.9% sodium chloride.

Obtain the client's vital signs every 5 min until the provider arrives.

Raise the head of the bed to 20°.

Answer and Explanation

The Correct Answer is B

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

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Correct Answer is D

Explanation

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne precautions, such as tuberculosis, but are not required for internal brachytherapy. Clients receiving internal radiation require a private room with appropriate shielding to limit radiation exposure.

B. Dispose of the radioactive source in the client's trash can: Radioactive sources should never be discarded in regular trash. If dislodged, the source must be handled properly using protective equipment and disposed of in a designated lead container to prevent radiation exposure.

C. Limit each visitor to 1 hr per day: Visitors should be limited to 30 minutes per day and should maintain a distance of at least 6 feet from the client. This minimizes radiation exposure to family members and healthcare providers.

D. Use long-handled forceps if the radioactive source is dislodged: If the internal radiation source becomes dislodged, it should never be touched directly. Long-handled forceps should be used to carefully place the source in a lead-lined container to protect against radiation exposure.

A. Fasting blood glucose level B. Glycosylated hemoglobin level C. Postprandial blood glucose level D. Oral glucose tolerance test results

Correct Answer is B

Explanation

A. Fasting blood glucose level: This test provides a snapshot of the client's blood glucose at a single point in time, typically after an overnight fast. While useful for daily monitoring, it does not reflect long-term glycemic control.

B. Glycosylated hemoglobin level: Hemoglobin A1c measures average blood glucose levels over the past 2 to 3 months, making it the most reliable indicator of long-term glycemic control. A target level below 7% is recommended for most individuals with diabetes.

C. Postprandial blood glucose level: This test evaluates blood sugar levels after meals but only provides short-term information about glucose fluctuations rather than an overall picture of glycemic control.

D. Oral glucose tolerance test results: This test is primarily used to diagnose diabetes and gestational diabetes rather than to monitor long-term control in individuals already diagnosed with diabetes.

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A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?

Nursing Test Bank

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