An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?
Evisceration.
Hemorrhage.
Infection.
Dehiscence.
The Correct Answer is A
A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.
Correct Answer is B
Explanation
A. Move away from the overbed table: This action can be done after the gloves are completely removed and disposed of. Moving away too early increases the risk of bumping into something and contaminating the gloves.
B. Sterile gloves are contaminated on the outside after performing a procedure like a dressing change. Pulling the glove down and everting it (turning it inside out) confines the contamination to the inside of the glove, reducing the risk of transferring germs to the hands or surrounding surfaces. This maintains a sterile field and minimizes the risk of healthcare-associated infections (HAIs).
C. Loosen the glove from the fingers: This might be the initial step while grasping the glove for removal, but the key is to maintain aseptic technique by keeping the outside of the glove contained throughout removal.
D. Raise the hands above waist level: Raising hands above the waist level increases the risk of contaminating the sterile field or nearby surfaces if the glove integrity is compromised.
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