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 B

Explanation

A. Sexual activity is known to increase endorphin levels, contributing to feelings of pleasure and relaxation.

B. Morphine does not increase endorphin levels; it mimics endorphins by binding to opioid receptors, but it does not cause the body to produce more endorphins.

C. Exercise, particularly intense physical activity, stimulates endorphin production, leading to the "runner's high."

D. Laughter is a natural way to boost endorphin levels, contributing to a sense of well-being.

A. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." B. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart" C. "Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration." D. "Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath."

Correct Answer is B

Explanation

A. Nitroglycerin does not dissolve blood clots; it works by dilating blood vessels to increase blood flow.

B. Nitroglycerin dilates the coronary arteries, increasing oxygen delivery to the heart muscle and relieving angina, which is caused by reduced blood flow to the heart.

C. Nitroglycerin is not used to relieve nausea or prevent vomiting; it is used primarily to manage chest pain.

D. Nitroglycerin is not a bronchodilator; it does not affect the airways directly but rather improves blood flow to the heart.

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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?

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Naxlex Comprehensive Predictor Exams

All of the following increase endorphin levels except

Correct Answer is B

Explanation

A nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, "Why am I taking nitroglycerin?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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