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 ["A","C","E"]
Explanation
Choice A reason: Making decisions for the patient can undermine their autonomy and is not therapeutic in treating Paranoid Personality Disorder.
Choice B reason: Avoiding situations that the patient may perceive as demeaning is actually an appropriate intervention, as it helps to build trust and rapport.
Choice C reason: Greatly limiting social contact is not recommended as it can increase feelings of isolation and paranoia.
Choice D reason: Avoiding discussion of the treatment plan is not appropriate; patients should be involved in their care decisions to the greatest extent possible.
Choice E reason: Maintaining honest, open communication is an appropriate and necessary intervention for building a therapeutic relationship with a patient with Paranoid Personality Disorder.
Correct Answer is D
Explanation
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today