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","D","E"]

Explanation

Choice A reason: A rational fear of certain objects is not typically associated with OCD, which is characterized by irrational fears or obsessions.

Choice B reason: Clients with OCD are usually very aware of their compulsions, even if they cannot control them.

Choice C reason: Rule-conscious behavior is common in OCD, as individuals may create strict routines to manage their anxiety.

Choice D reason: Difficulty relaxing is a characteristic of OCD due to persistent intrusive thoughts and compulsive behaviors.

Choice E reason: Perfectionist behavior is often seen in OCD, where there is an excessive concern with orderliness and details.

A. Permanent mobility impairment B. A delay of healing C. Malalignment of healed bones D. The development of a bone infection

Correct Answer is B

Explanation

Choice A reason: Permanent mobility impairment is a possible complication, but it is not the most common concern immediately following a closed reduction and cast placement.

Choice B reason:Older adults are at a higher risk for delayed healing of fractures due to factors such as reduced bone density, slower cellular repair mechanisms, and potential comorbidities like diabetes or osteoporosis. While permanent mobility impairment, malalignment, and bone infections are possible complications of fractures, they are less common in routine cases of closed reduction and casting, especially if proper care and follow-up are provided. Delayed healing is a more likely complication due to age-related changes in bone health.

Choice C reason: Malalignment of healed bones is a potential long-term complication, but it is not the immediate concern post-cast placement.

Choice D reason: Bone infections (osteomyelitis) are rare following closed fractures treated with casting, especially when there is no open wound. Infections are more likely with open fractures or surgical interventions.

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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

A nurse is collecting data from a client who reports that he has obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

An older adult patient experiences a fracture of the lower leg and undergoes closed reduction and placement of a fiberglass cast. What should the nurse prepare for when planning care?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

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When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

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