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

The correct answer is D.

Social worker. The rationale is that a social worker can help the client access community resources and transportation services that can facilitate their attendance to follow-up appointments. The social worker can also assess and address any psychosocial barriers that may affect the client's adherence to treatment.

A. Cleanse the inner cannula with isopropyl alcohol B. Prepare sterile supplies after removing the inner cannula. C. Clean the stoma using an inward to outward circular motion D. Ensure at least three finger widths of space under tracheostomy ties.

Correct Answer is C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

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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

A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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