A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Use sterile gloves to place gentle pressure on the exposed organs.

Have the client lie supine with legs straight.

Cover the area with saline-soaked sterile dressings.

Gently suction secretions from the wound bed using a 12 gauge sterile catheter.

Answer and Explanation

The Correct Answer is C

A. Placing pressure on exposed organs is not appropriate and could cause further damage.

B. Having the client lie supine with legs straight could increase tension on the abdominal wound and exacerbate the evisceration.

C. Covering the eviscerated organs with saline-soaked sterile dressings is the correct intervention to protect the organs from infection and prevent them from drying out while waiting for emergency surgical intervention.

D. Suctioning secretions from the wound bed is not appropriate and could cause additional trauma to the exposed organs.

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Correct Answer is C

Explanation

A. Albuterol may be used to treat bronchospasm associated with anaphylaxis, but it is not the first-line treatment.

B. Hydrocortisone sodium succinate is a corticosteroid that can help reduce inflammation, but it is not the first-line treatment in acute anaphylaxis.

C. Epinephrine is the first-line treatment for anaphylactic shock. It acts quickly to constrict blood vessels, increase heart rate, and open airways, counteracting the severe allergic reaction.

D. Diphenhydramine is an antihistamine that can help alleviate allergic symptoms but should be given after epinephrine in anaphylactic emergencies.

A. Pedal edema B. Dysphagia C. Distended neck veins D. Dyspnea

Correct Answer is D

Explanation

A. Pedal edema is related to fluid retention or circulatory issues, not atelectasis.

B. Dysphagia, or difficulty swallowing, is not typically associated with atelectasis.

C. Distended neck veins are a sign of increased central venous pressure, not atelectasis.

D. Dyspnea, or difficulty breathing, is a common sign of atelectasis, which is the collapse of part or all of a lung, leading to impaired gas exchange.

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A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate?

Nursing Test Bank

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Correct Answer is D

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