A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
Cover the wound with sterile, saline-soaked gauze.
Raise the head of the bed to a 45° angle.
Hold gentle, direct pressure on the protruding organ
Place the client's knees in an extended position.
The Correct Answer is A
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
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Related Questions
Correct Answer is A
Explanation
The correct answer is A. Promoting trust. Trust is essential for establishing a therapeutic relationship with the client and facilitating their recovery. The nurse demonstrates trustworthiness by responding to the client's needs in a timely and respectful manner, and by providing them with a healthy meal that meets their nutritional requirements.
Correct Answer is A
Explanation
To calculate the percentage of weight loss, we can use the formula:
Percentage of weight loss = (Weight loss / Original weight) * 100
Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:
Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%
The percentage of weight loss is approximately 7.49%.
Since none of the provided answer options exactly match this calculated percentage, the closest option is:
So, the nurse should identify the weight loss as approximately 7.5%.
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