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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.
Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.
Choice B reason:
Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.
Choice C reason:
Temperature: The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. Unless there are specific signs or symptoms of fever or infection, reporting the temperature is not necessary based on the given data.
Choice D reason
Bowel sounds: The provided information does not include any data about the client's bowel sounds, and there are no indications of gastrointestinal issues or abnormalities. Bowel sounds may not be relevant to report unless there are specific symptoms or signs of GI disturbances.
Correct Answer is D
Explanation
The correct answer is choice d. Measure the client’s abdominal girth daily.
Choice A rationale:
Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.
Choice B rationale:
Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.
Choice C rationale:
Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.
Choice D rationale:
Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.
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