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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?

A.

Cover the wound with sterile, saline-soaked gauze.

B.

Raise the head of the bed to a 45° angle.

C.

Hold gentle, direct pressure on the protruding organ

D.

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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Related Questions

Correct Answer is A

Explanation

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

Correct Answer is D

Explanation

The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .

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