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 B
Explanation
Choice A reason: Recurrent thoughts of past trauma are more indicative of post-traumatic stress disorder rather than schizophrenia.
Choice B reason: Inventing new words or phrases that have no meaning, also known as neologisms, is a common positive symptom of schizophrenia.
Choice C reason: A preoccupation with washing and folding clothes is not specifically indicative of schizophrenia; it could be a sign of obsessive-compulsive disorder.
Choice D reason: While social withdrawal can be a symptom of schizophrenia, it is considered a negative symptom, not a positive one.
Correct Answer is D
Explanation
Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.
Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.
Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.
Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.
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