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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. This is a measurable goal as it has a specific action, which is to identify five major drug side effects, and a specific time frame, which is before discharge tomorrow. The goal is also realistic and achievable within the given time frame. Option A, sitting out of bed in the chair, is not specific enough and lacks a time frame. Option B, verbalizing feelings about surgery at some point, is too vague and lacks a specific action and time frame. Option C, eating low-sodium food, is specific but lacks a time frame and may not be realistic given the client's condition.
Correct Answer is C
Explanation
The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.
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