A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Trendelenburg with legs extended

Supine with knees flexed

Semi-Fowler's with legs extended

Left-lateral with knees flexed

Answer and Explanation

The Correct Answer is B

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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Correct Answer is A

Explanation

A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The first action the nurse should take is to assess neurovascular status followed by notify the provider.

Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.

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A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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