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 A

Explanation

Choice A reason: A positive pregnancy test is a significant concern for a patient preparing for surgery as it can affect the type of anesthesia used and the surgical approach, due to the potential impact on the fetus.

Choice B reason: While a family history of hypertension is important, it is not as immediately concerning as a positive pregnancy test in a patient preparing for surgery.

Choice C reason: A signed advance directive is a document that outlines a patient's wishes regarding medical treatment and is not a concern but rather a part of preoperative preparation.

Choice D reason: A medical history of diabetes is important to consider in surgical patients due to potential complications with wound healing and blood glucose control, but it is not as urgent as confirming pregnancy status before surgery.

A. Thinking/content of thought B. Mood and affect C. Judgment D. Perception

Correct Answer is D

Explanation

Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.

Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.

Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.

Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.

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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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Explanation

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Correct Answer is D

Explanation

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