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°.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Thalassemia: A genetic blood disorder affecting hemoglobin production. While patients with severe anemia may have an increased bleeding risk, thalassemia itself is not a contraindication to heparin. Caution is needed if the patient has splenomegaly or significant anemia.
B. Rheumatoid arthritis: An autoimmune condition that can increase bleeding risk due to chronic inflammation and medication use, such as NSAIDs or corticosteroids. However, heparin is not contraindicated unless there is an associated bleeding disorder or severe thrombocytopenia.
C. Thrombocytopenia: A condition characterized by a low platelet count, significantly increasing the risk of bleeding. Heparin use can worsen this condition, especially in cases of heparin-induced thrombocytopenia (HIT), which can lead to both bleeding and thrombosis.
D. COPD: A chronic lung disease that does not directly contraindicate heparin therapy. While COPD patients may be at risk for deep vein thrombosis due to immobility, heparin remains a standard prophylactic treatment unless there are other bleeding risks.
Correct Answer is ["A","B","E"]
Explanation
A. Verify the solution with another RN prior to infusion: TPN is a high-risk therapy that requires verification by two RNs to ensure the correct formulation, preventing medication errors that could lead to severe complications.
B. Monitor serum blood glucose during infusion: TPN contains high concentrations of glucose, increasing the risk of hyperglycemia. Regular blood glucose monitoring helps detect imbalances and allows for timely intervention.
C. Increase the rate of infusion if administration is delayed: Increasing the infusion rate can lead to metabolic complications such as hyperglycemia and fluid overload. If TPN is delayed, the provider should be consulted for adjustments rather than increasing the rate independently.
D. Infuse 0.9% sodium chloride if the solution is not available: If TPN is unavailable, the correct alternative is an infusion of dextrose 10% in water (D10W) to prevent hypoglycemia, not 0.9% sodium chloride, which lacks glucose.
E. Obtain the client's weight daily: Daily weights help monitor fluid balance, nutritional status, and potential complications such as fluid retention or dehydration, ensuring proper TPN management.
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