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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Direct communication with the surgeon can provide the patient with reassurance and specific information about the surgery, which may alleviate fears.

Choice B reason: Offering spiritual support may be helpful, but it does not directly address the patient's concern about the surgery itself.

Choice C reason: Providing statistics may be reassuring, but it may not fully address the patient's individual fears.

Choice D reason: Recommending analgesics only addresses pain management and not the patient's expressed fear regarding the surgery.

A. Legs in adduction B. More than 90-degree hip flexion C. Internal leg rotation D. Legs in abduction

Correct Answer is D

Explanation

Choice A reason: Legs in adduction can increase the risk of dislocation after hip replacement surgery.

Choice B reason: Flexing the hip more than 90 degrees can also increase the risk of dislocation.

Choice C reason: Internal rotation of the leg can lead to dislocation of the new hip joint.

Choice D reason: Maintaining the legs in abduction helps to stabilize the hip and prevent dislocation.

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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?

Nursing Test Bank

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