The nurse enters a client's room to find that his abdominal wound has eviscerated.
Which intervention should the nurse implement first?

Place the client in reverse Trendelenburg position

Administer IV antibiotics STAT

Use sterile gloves to replace the protruding parts

Apply a sterile normal saline dressing

Answer and Explanation

The Correct Answer is D

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

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Correct Answer is B

Explanation

Choice A rationale: Using a small gauge needle may reduce pain but does not specifically address tissue irritation.

Choice B rationale: The Z-track method is used to reduce irritation and prevent leakage of irritating medications into the subcutaneous tissues.

Choice C rationale: Administering at a 45-degree angle is a common angle for intramuscular injections but does not specifically address tissue irritation.

Choice D rationale: Applying ice to the injection site is not a standard practice for reducing tissue irritation with intramuscular injections.

A. Give the medication anyway because it's important for the client B. Withhold the medication and report it to the prescriber C. Withhold the medication and file an incident report D. Inform the client that the medication must be taken until the nurse gets an order to discontinue it

Correct Answer is B

Explanation

Choice A rationale: Administering the medication against the client's will is not respectful of the client's autonomy and right to make decisions about her own care.

Choice B rationale: Withholding the medication and reporting it to the prescriber is appropriate. The prescriber can reassess the situation and determine the next course of action.

Choice C rationale: Withholding the medication and filing an incident report may be premature; it is essential to involve the prescriber first.

Choice D rationale: Informing the client that the medication must be taken until the nurse gets an order to discontinue it may not be the best approach, as it does not respect the client's right to refuse treatment. The prescriber should be involved in the decision-making process.

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The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues, which action should the nurse take?

Correct Answer is B

Explanation

An alert, competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?

Correct Answer is B

Explanation

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The nurse enters a client's room to find that his abdominal wound has eviscerated.
Which intervention should the nurse implement first?