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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Hyperactive bowel sounds are high-pitched and occur at a rate of more than 30/min. They indicate increased motility and can be a result of diarrhea, inflammation, infection, or bleeding.
Correct Answer is B
Explanation
B. “I should discuss this document with my family after I sign it.”It is important for clients to discuss their advance directives with their family members to ensure that their wishes are understood and respected. This helps prevent confusion and ensures that family members are aware of the client’s preferences for end-of-life care.
Incorrect Options:
A. “I am not allowed to change my mind once I sign this document.”Clients can change or revoke their advance directives at any time as long as they are competent to do so.
C. “My partner needs to be present when I sign this document.”While it is a good idea to have a witness, it is not necessary for the partner to be present. The requirements for witnesses vary by jurisdiction.
D. “An attorney will need to notarize this document for it to be valid.”Not all advance directives require notarization. The requirements vary by state or country, and some may only require witnesses.
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