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 B

Explanation

Choice A reason: While legs feeling heavy can be a common sensation after a spinal block, it is not as concerning as other potential symptoms.

Choice B reason: Hypotension is a significant concern following a spinal block as it can indicate a high level of blockage affecting the autonomic nerves, which can lead to serious complications.

Choice C reason: Numbness below the injection site is expected after a spinal block and is not typically a cause for concern unless it is prolonged or accompanied by other symptoms.

Choice D reason: Nausea can occur but is less concerning than hypotension, which can have more immediate and severe consequences.

A. The stockings prevent venous stasis. B. The stockings replace the need for postoperative leg exercises. C. The stockings prevent varicose veins. D. The stockings are used to reduce pain.

Correct Answer is A

Explanation

Choice A reason: Antiembolism stockings are designed to apply pressure to the lower legs, promoting blood circulation and preventing blood from pooling in the veins, which can lead to venous stasis.

Choice B reason: While antiembolism stockings aid in circulation, they do not replace the need for postoperative leg exercises, which are important for recovery.

Choice C reason: These stockings are not specifically used to prevent varicose veins; their primary purpose is to prevent deep vein thrombosis (DVT) in postoperative patients.

Choice D reason: The stockings are not primarily used for pain reduction; their main function is to improve venous return and prevent DVT.

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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?

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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?