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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 D

Explanation

A. Altered nutrition is a concern but is not the immediate priority.
B. Activity intolerance is expected but does not pose an immediate threat.
C. Fluid volume excess should be monitored, but ineffective airway clearance poses a more immediate risk.
D. Ineffective airway clearance is the highest priority because a flank incision can cause significant pain, leading to shallow breathing and increased risk for atelectasis or pneumonia.

A. Observe him as he demonstrates the self-injection technique to another diabetic adolescent. B. Review his glycosylated hemoglobin level 3 months after the teaching session. C. Have the adolescent list the procedural step for safe insulin administration. D. Ask the adolescent to describe his level of comfort with injecting himself with insulin.

Correct Answer is C

Explanation

A: Observing the adolescent demonstrate the technique to another person may be helpful, but it does not directly assess the adolescent’s own ability to perform the skill.

B: Reviewing glycosylated hemoglobin levels 3 months later will not assess the immediate effectiveness of the teaching or the adolescent’s ability to perform insulin injections.

C: Asking the adolescent to list the steps ensures that they can recall and understand the procedure, confirming that the teaching has been effective and that the adolescent is capable of performing insulin injections safely.

D: Asking about comfort level is important for emotional support but does not directly assess the technical competency required for insulin administration.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Correct Answer is D

Explanation

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct Answer is C

Explanation

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Patient Data

Exhibits

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