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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.

Notify the surgeon

Place the client in low-Fowler's with knees raised

Start a peripheral IV (PIV)

Cover the wound with moistened sterile gauze

Hold pressure on the dressing

Encourage the client to drink fluids

Assist the client to cough and deep breathe

Answer and Explanation

Correct Answer : A,C,D

A. Notify the surgeon: The client has developed a wound dehiscence with evisceration of intestinal tissue, which is a serious surgical complication. Immediate communication with the surgeon is necessary to determine the next steps for repair and to avoid further complications, such as infection or organ injury.

B. Place the client in low-Fowler's with knees raised: While positioning is important for comfort and reducing pressure on the abdomen, placing the client in low-Fowler’s position is not the priority. The focus should be on protecting the eviscerated tissue and managing potential hypovolemia.

C. Start a peripheral IV (PIV): Starting a PIV is essential for administering fluids and medications, especially if the client requires resuscitation or further surgical intervention. The client's vital signs (decreased blood pressure, increased heart rate) suggest potential hypovolemia or shock, which may require IV fluids for stabilization.

D. Cover the wound with moistened sterile gauze: Evisceration requires immediate intervention to protect the exposed tissue. The nurse should cover the wound with sterile gauze that is moistened with normal saline to prevent the exposed intestines from drying out and to reduce the risk of infection. This is a critical step in managing the wound before further surgical intervention.

E. Hold pressure on the dressing: Applying pressure to the surgical dressing is not appropriate in this situation because it could cause more harm or further disrupt the wound. The wound should be covered with moistened sterile gauze to protect the eviscerated tissue, not pressured.

F. Encourage the client to drink fluids: Oral intake is not appropriate in the acute post-surgical phase when the client has experienced evisceration. The client may require surgical repair, and fluids should be administered intravenously to avoid the risk of aspiration or bowel perforation.

G. Assist the client to cough and deep breathe: While respiratory exercises are important for preventing atelectasis and pneumonia post-operatively, they are not an immediate priority in this situation where the client has evisceration. Stabilizing the wound and addressing potential shock takes precedence.

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Correct Answer is B

Explanation

A. Carrots are a good source of vitamin A, but they do not provide sufficient calcium or vitamin D for bone health.

B. Low-fat yogurt is an excellent source of calcium and vitamin D, which are important for postmenopausal women at risk for osteoporosis due to hormonal changes.

C. Beets are nutritious but are not particularly relevant for improving bone health.

D. Mixed berries are a great source of antioxidants but do not provide the same bone-strengthening nutrients as low-fat yogurt.

A. Administer a PRN dose of regular insulin. B. Give the client 4 ounces (120 mL) of orange juice. C. Provide the client with 1/2 cup (120 mL) diet carbonated soda. D. Obtain blood pressure and heart rate. E. Check the client's current fingerstick blood glucose.

Correct Answer is ["B","D","E"]

Explanation

A. Administering insulin would be inappropriate if the client is hypoglycemic, as it would further lower the blood glucose.

B. Giving 4 ounces (120 mL) of orange juice provides a fast-acting source of glucose to treat hypoglycemia, which is likely causing confusion and weakness.

C. A diet carbonated soda contains artificial sweeteners and may not provide the immediate glucose needed in this situation.

D. Checking blood pressure and heart rate is important to assess for potential causes of the symptoms.

E. A fingerstick blood glucose test is necessary to confirm if hypoglycemia is the cause of the symptoms.

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Patient Data Exhibits Which should the nurse immediately do? Select all that apply.

Nursing Test Bank

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Patient Data

Exhibits

Which should the nurse immediately do? Select all that apply.