The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Cover the bowel with a sterile saline dressing.

Raise the patient up to a high Fowler's position.

Call the RN.

Turn the patient to the side of the evisceration.

Answer and Explanation

The Correct Answer is A

A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.

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Correct Answer is B

Explanation

A. Leaning against a bedside table does not provide adequate support or comfort for coughing.
B. Splinting the abdomen with a pillow supports the incision site and reduces pain, making it easier for the patient to cough effectively.
C. Supporting the patient's back is helpful but not as effective as abdominal splinting for reducing pain during coughing.
D. Offering an antitussive is not appropriate as it suppresses coughing, which is needed to clear secretions postoperatively.

A. Maturation B. Proliferation C. Inflammation D. Remodeling phase

Correct Answer is C

Explanation

A. The maturation phase is the final phase of wound healing and involves the strengthening and remodeling of collagen fibers.
B. The proliferation phase is the second phase of wound healing, characterized by the formation of new tissue and blood vessels.
C. The inflammation phase is the first phase of wound healing, during which the body's initial response to injury involves hemostasis and inflammation. This phase includes vasodilation, increased permeability of blood vessels, and the influx of white blood cells to clean the wound.
D. The remodeling phase is another term for the maturation phase, the final phase of wound healing.

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The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What technique will the nurse implement to assist the postoperative patient to cough?

Correct Answer is B

Explanation

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?

Correct Answer is C

Explanation

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