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.

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

A. Tie the gown with the gloves on. B. Tuck the glove cuffs under the gown sleeves. C. Apply the gown before the gloves. D. Push the gown sleeves up to the elbows.

Correct Answer is C

Explanation

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.

The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.

The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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