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 C
Explanation
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.
Correct Answer is B
Explanation
A. "Don't worry, I'm sure your son will visit."
This response is dismissive and assumes that the son will visit, which may not be the case. It may come across as insensitive.
B. "Your son hasn't been around much lately?"
This response reflects the patient's statement, encouraging them to elaborate. It shows empathy and gives the patient space to express their feelings.
C. "My son doesn't come to visit me either."
This response shifts focus away from the patient and may make them feel that their concern is trivialized.
D. "How terrible that he doesn't visit you."
This response is judgmental and might make the patient feel worse or lead them to think the nurse disapproves of their son.