A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Position the client so that they are lying flat.

Increase the client's oral fluid intake.

Prepare the client for emergency surgery.

Apply gentle pressure to the dressed wound.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

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Free Nursing Study Resources

Correct Answer is ["50"]

Explanation

Step 1: The total volume of the solution is 100 mL and it needs to be infused over 2 hours.

Step 2: To find the rate in mL/hr, divide the total volume by the total time.

Step 3: Calculation is (100 mL ÷ 2 hr).

Step 4: The IV pump should be set to deliver 50 mL/hr. This is the final answer, rounded to the nearest whole number as required.

A. "I'll use the cane to support my body weight.". B. "I will put the cane next to my right leg when I walk.". C. "My partner is bringing in a wooden cane we have at home.". D. "I will move my right leg forward first.".

Correct Answer is B

Explanation

Choice A rationale:

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

Choice B rationale:

Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.

Choice C rationale:

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Choice D rationale:

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

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A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["50"]

Explanation

A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

Correct Answer is B

Explanation

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