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 A
Explanation
The correct answer is A. Clean the wound from the center to the outer edges.
Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.
The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.
Correct Answer is B
Explanation
The correct answer is B.
Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.
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