A nurse is caring for a client who is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding. After contacting the rapid response team, which of the following actions should the nurse take next?
Obtain a set of vital signs.
Flex the client's knees and hips.
Apply a moist saline dressing to the area.
Elevate the head of the client's bed 20°.
The Correct Answer is C
The correct answer is c. Apply a moist saline dressing to the area.
Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.
Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.
Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.
Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.
Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.
Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.
Correct Answer is B
Explanation
"The lesions may reoccur in times of stress." This statement indicates that the client understands that the virus can reactivate and cause new outbreaks during times of stress.
Choice A is not correct because thevirus can spread to other areas through skin-to-skin contact.
Choice C is not correct because the virus can still be contagious even when no lesions are present.
Choice D is not correct because having unprotected sex can still transmit the virus even while taking acyclovir.
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