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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Inspect the mouth once each week for sores: Frequent oral assessments are necessary, especially after a partial glossectomy, to monitor for infection, healing complications, or signs of malignancy recurrence. Checking only once per week is insufficient for early detection of issues.

B. Use text or pictures to communicate needs postoperatively: A partial glossectomy can impair speech, making communication difficult. Using alternative methods such as writing, text, or pictures helps ensure effective communication, especially in the immediate postoperative period.

C. Rinse with an alcohol-based mouthwash instead of brushing: Alcohol-based mouthwashes can cause irritation and delay healing. Instead, gentle oral hygiene with a soft toothbrush and non-alcoholic rinses like saline or chlorhexidine is recommended to maintain cleanliness without irritation.

D. Increase intake of dense, high-fiber foods: Soft, easy-to-swallow foods are preferred after a partial glossectomy to prevent irritation and facilitate healing. Dense, high-fiber foods can be difficult to chew and may cause discomfort, increasing the risk of aspiration or delayed wound healing.

A. Flushed cheeks B. Severe headaches C. Low-grade fever D. Dry cough

Correct Answer is C

Explanation

A. Flushed cheeks: Tuberculosis typically presents with systemic symptoms such as fever, night sweats, and weight loss rather than flushed cheeks. Flushing is more commonly associated with fever spikes in other infections or conditions like menopause.

B. Severe headaches: Tuberculosis can cause headaches if it leads to tuberculous meningitis, but this is not a common initial symptom of pulmonary tuberculosis. Headaches are not a hallmark feature of active TB infection.

C. Low-grade fever: A persistent low-grade fever, particularly in the afternoon or evening, is a common symptom of tuberculosis. It is often accompanied by night sweats and weight loss due to the chronic inflammatory response.

D. Dry cough: The cough associated with tuberculosis is usually productive with purulent or blood-tinged sputum rather than dry. The infection causes lung tissue destruction, leading to a persistent cough with mucus production.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is postoperative following a partial glossectomy. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is admitting a client who has tuberculosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A home health nurse is planning to use nonpharmacological pain relief measures for a client who has severe chronic back pain. Which of the following pain management guidelines should the nurse use?

A nurse is caring for a client who has a nasogastric tube. The nurse should monitor the client for which of the following findings?

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis?

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020. Select the 2 findings that indicate the client's condition is improving.

A nurse is caring for a client who has developed a paralytic ileus related to acute pancreatitis and reports pain as 8 on a scale of 0 to 10. The client has prescriptions for multiple PRN pain medications. Which of the following medications should the nurse administer?