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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.
Correct Answer is A
Explanation
Choice A reason:
Among the options listed, cheese is the food that is contraindicated with MAOI use. Cheese is high in tyramine, and consuming it while taking MAOIs can lead to a potentially life-threatening hypertensive crisis.
An MAOI (Monoamine Oxidase Inhibitor) is a type of medication used to treat depression, anxiety, and other psychiatric disorders. When taking MAOIs, it is important to avoid certain foods that contain high levels of tyramine, as it can lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Choice B reason:
Potatoes: Potatoes are not contraindicated with MAOI use. They do not contain significant levels of tyramine.
Choice C reason:
Grapefruit: Grapefruit is not contraindicated with MAOI use. However, it can interact with certain medications, so it's always a good idea to check with the healthcare provider or pharmacist about specific medication interactions.
Choice D reason:
D. Eggs: Eggs are not contraindicated with MAOI use. Like potatoes, they do not contain significant levels of tyramine.
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