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
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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Related Questions
Correct Answer is C
Explanation
A. "Insert an indwelling urinary catheter and record the client's output.": This is not relevant to a thoracentesis, which focuses on the pleural cavity, not urinary output.
B. "Set up the equipment using clean technique.": Sterile technique is required to prevent infection during the invasive procedure.
C. "Prepare the client for a chest x-ray following the procedure.": A chest x-ray is performed post-thoracentesis to ensure the lung has re-expanded and to rule out complications like pneumothorax.
D. "Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.": The client does not need to remain flat; instead, they are typically observed for respiratory complications in a sitting or semi-Fowler’s position.
Correct Answer is C
Explanation
A. Start the prescribed antibiotic: There is no indication of infection in the current clinical findings; antibiotics are typically used to treat bacterial infections, which are not yet evident.
B. Discontinue nasogastric tube: The nasogastric tube should remain in place as it helps relieve the symptoms of small bowel obstruction (e.g., vomiting and bloating).
C. Reinforce preoperative teaching: The client is on NPO status, which may suggest preparation for a surgical intervention to address the obstruction. Reinforcing preoperative teaching would be beneficial to ensure the client understands the procedure.
D. Provide the client with ice chips: The client is on NPO status, and consuming food or fluids is contraindicated due to the potential for aspiration or worsening of the condition (e.g., bowel obstruction or pancreatitis).
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