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: While injury and age can be risk factors, they are not the greatest contributors to RA, which is an autoimmune disease.

Choice B reason: Heat therapy can help relieve pain in some cases, but it is not always the best response for acutely inflamed joints; cold therapy is often recommended to reduce inflammation.

Choice C reason: RA can affect multiple body systems beyond the joints, including the cardiovascular and respiratory systems, so it is essential to monitor all body systems.

Choice D reason: Exercise is actually beneficial for patients with RA to maintain joint function and muscle strength; rest is important, but should be balanced with physical activity.

A. Extend the scheduled time, as the client is finally able to discuss important feelings. B. End at the scheduled time, telling the client that he can continue at the next scheduled session. C. Arrange for another nurse to continue the interview. D. Set an extra meeting time to discuss the client's feelings.

Correct Answer is B

Explanation

Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.

Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.

Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.

Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.

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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

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a patient with rheumatoid arthritis (RA). What should the nurse consider when providing care?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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