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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Correct Answer is B
Explanation
Explanation: The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
Correct Answer is D
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The correct answer is D. I should expect pain relief in 1 to 3 minutes. Sublingual nitroglycerin tablets are placed under the tongue and dissolve quickly to relieve chest pain caused by angina. The medication works by dilating blood vessels and improving blood flow to the heart. The onset of action is usually within 1 to 3 minutes.
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