A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Obtain a sample of the drainage to send to the laboratory.
Auscultate the abdomen for bowel sound activity.
Prepare the client to return to the operating room.
Bring additional sterile dressing supplies to the room.
The Correct Answer is C
A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.
B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.
C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.
D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.
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Correct Answer is B
Explanation
A. restatement. Restatement involves repeating the patient’s words exactly, while here, the nurse is rephrasing the sentiment.
B. reflection. Reflection focuses on the patient’s feelings or experiences by paraphrasing their statement, helping the patient explore their feelings, which the nurse is doing here.
C. open-ended question. An open-ended question would be broad, allowing the patient to provide more information. This response is a restatement, not a question.
D. offering self. Offering self involves expressing a willingness to stay or support the patient, which is not demonstrated here.
Correct Answer is A
Explanation
A. Wearing braces or splints on both wrists at night helps to keep the wrists in a neutral position, preventing flexion that can worsen symptoms of carpal tunnel syndrome, particularly during sleep when the hands are more likely to be positioned in ways that exacerbate compression of the median nerve.
B. While notifying the healthcare provider is important if symptoms are severe, it is not the immediate teaching intervention the nurse should provide for symptom management.
C. Elevating the hands may help with swelling but is not the primary intervention for managing symptoms of carpal tunnel syndrome, especially pain and tingling.
D. Cold compresses may provide temporary relief but do not address the underlying issue of median nerve compression, which is better managed by using wrist braces.