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 D

Explanation

Choice A reason:

This is a mild analgesic and antipyretic. It may be inadequate for moderate pain such as that from cholelithiasis (gallstones).

Choice B reason:

Omeprazole Omeprazole should not administer because it is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. It is not indicated for the treatment of pain and discomfort associated with cholelithiasis.

Choice C reason

Should not be administered

Metoclopramide Metoclopramide should not be administered because it is a medication used to treat gastrointestinal issues such as nausea, vomiting, and gastroparesis. It is not indicated for the treatment of pain associated with cholelithiasis.

Choice D reason:

Ketorolac: This is a nonsteroidal anti-inflammatory drug (NSAID) appropriate for moderate to severe pain, including biliary colic due to cholelithiasis. It is often used PRN for acute pain relief.

A. Tachycardia B. Cramping C. Seizures D. Elevated temperature

Correct Answer is C

Explanation

Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.

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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 D

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Correct Answer is C

Explanation

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