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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Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Using the continuous passive-motion machine intermittently helps to prevent joint stiffness and promote circulation in the surgical leg. Applying warm, moist packs to the surgical site can increase inflammation and infection risk. Placing a pillow under the client's surgical knee can cause flexion contractures and impair healing. Massaging the lower leg in smooth, long strokes can dislodge a thrombus and cause a pulmonary embolism.
Correct Answer is D
Explanation
The correct answer is D.
Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.
The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.
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