Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

Pour sterile hydrogen peroxide into the abdominal cavity and pack it with gauze.

Pour normal saline on the area and gently place organs back into the cavity.

Attempt to close the wound area with reinforced adhesive skin closures.

Cover the wound area with sterile gauze moistened with sterile 0.9% normal saline.

Answer and Explanation

The Correct Answer is D

Upon discovering that the client's abdominal wound has been eviscerated, the nurse should immediately cover the wound area with sterile gauze moistened with sterile 0.9% normal saline. This will help to protect the exposed organs and prevent them from becoming dry or exposed to contaminants. Pouring hydrogen peroxide into the abdominal cavity can cause further damage to the exposed organs and is not recommended. Similarly, normal saline should be gently poured on the area to moisten it, but organs should not be placed back into the cavity as this can cause further injury. Attempting to close the wound area with reinforced adhesive skin closures is also not appropriate as the wound needs to be assessed and repaired by a healthcare provider. The nurse should call the healthcare provider and provide ongoing assessment and support to the client while waiting for further interventions.

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Correct Answer is ["A","C","E"]

Explanation

The correct answer is choices A, C, and E.

Stool is hard and has a consistency of small marbles is a sign of constipation.
Bowel sounds that are hyperactive in all four quadrants are an indication of diarrhea rather than constipation.
Client reports they have not had a bowel movement for the past 4 days supports the diagnosis of constipation.
Client reports urgency when needing to have a bowel movement is more indicative of diarrhea than constipation.
Client states they have to strain hard when having a bowel movement is a sign of constipation.

A. Hot cereals, ice cream, chocolate milk B. Frozen dessert, egg substitutes C. High-calorie, high-protein milk-based supplements D. Jell-O, broth, apple juice

Correct Answer is D

Explanation

The correct answer is choice D, Jell-O, broth, apple juice. A clear liquid diet consists of fluids and foods that are clear and liquid at room temperature. These foods are easy to digest and leave no residue in the gastrointestinal tract. Examples include water, clear fruit juices, clear broths, tea, coffee without cream, and Jell-O.

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Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A patient has been prescribed a clear liquid diet. What food or fluids will be served?

Correct Answer is D

Explanation

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Which of the following is the best example of a measurable client goal? The clientwill:

A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having painful burning with urination. How should the nurse document the client's condition?

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The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?