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. A small, soft-bristled toothbrush is recommended for cleaning a toddler's teeth as it can remove plaque without damaging the gums. The bristles should be angled at 45 degrees, not 90 degrees, to reach under the gum line. A pea-sized amount of toothpaste, not a 5-inch strip, is sufficient for a toddler's toothbrush. Flossing is not necessary until two adjacent teeth touch each other, which usually happens around age 2 or 3.
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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