A nurse is caring for a client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. Upon examination, the nurse finds an evisceration. Which of the following interventions is appropriate?
Use sterile gloves to place gentle pressure on the exposed organs.
Have the client lie supine with legs straight.
Gently suction secretions from the wound bed using a 12-gauge sterile catheter.
Cover the area with saline-soaked sterile dressings.
The Correct Answer is D
Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.
Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.
Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.
Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Getting plenty of outdoor exercise all year is beneficial for overall health but does not specifically prevent Raynaud's attacks, especially in cold weather.
Choice B reason: Keeping affected body areas covered, especially in cold weather, helps prevent Raynaud's attacks by maintaining warmth.
Choice C reason: Taking vasopressors is not a measure to prevent Raynaud's attacks; vasopressors could potentially worsen the condition by causing further vasoconstriction.
Choice D reason: Avoiding stimulation that causes vasoconstriction, such as stress and cold temperatures, is key to preventing Raynaud's attacks.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because it suggests that higher oxygen levels trigger breathing, which is not the case in hypoxic drive.
Choice B reason: While carbon dioxide levels do influence breathing, this statement is not accurate in the context of hypoxic drive, which is specifically about oxygen levels.
Choice C reason: This choice is incorrect because the client does notice the need to breathe, but the trigger is low oxygen rather than high carbon dioxide levels.
Choice D reason: This is correct. In clients with COPD, chronic high levels of carbon dioxide can lead to a reliance on low oxygen levels to stimulate breathing.
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