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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Correct Answer is C

Explanation

Choice A rationale:

Determining what the client knows about coronary artery disease is an important step in assessing the client's baseline knowledge. However, it's not the first step in developing teaching strategies. First, the nurse should establish a collaborative relationship with the client to set mutual learning goals.

Choice B rationale:

Identifying resources that will help support the client's lifestyle changes is an essential aspect of the teaching process, but it's not the initial step. The nurse needs to work with the client to set goals and develop a plan before seeking external resources.

Choice C rationale:

Establishing mutual learning goals with the client is the most crucial first step. This approach ensures that the teaching plan aligns with the client's needs and preferences, fostering a sense of partnership and increasing the likelihood of successful lifestyle changes.

Choice D rationale:

Scheduling a teaching session about coronary artery disease in a quiet setting is an important consideration for effective teaching, but it comes after the nurse and the client have identified mutual learning goals. The nurse should engage the client in goal-setting before planning specific teaching sessions.

A. 30° lateral. B. Lateral semi-prone recumbent. C. Supine. D. 45° supported Fowler's.

Correct Answer is A

Explanation

The correct answer is choice A. 30° lateral.

Choice A rationale:

The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.

Choice B rationale:

The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.

Choice C rationale:

The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.

Choice D rationale:

The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.

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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

A nurse is caring for a client who has coronary artery disease and has a BMI of 30. Which of the following strategies should the nurse implement first to develop teaching that promotes lifestyle changes?

Correct Answer is C

Explanation

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

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