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 C
Explanation
The correct answer is C. Effleurage is a type of massage that involves gently stroking or rubbing the abdomen during contractions to provide comfort and distraction. It can also stimulate endorphin release and reduce pain perception. Breathing deeply at the beginning of each contraction is a relaxation technique, not effleurage. Applying pressure to the sacral area with a tennis ball is a counterpressure technique, not effleurage. Focusing on an object in the room is a focal point technique, not effleurage.
Correct Answer is D
Explanation
The correct answer is D. The telephone numbers of the clients are unique identifiers that can be used to verify their identities before administering medications. The room numbers, diagnoses, and names of relatives are not reliable identifiers because they can change or be shared by other clients.
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