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 D
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.
Correct Answer is B
Explanation
A. Removing ink marks can lead to difficulty in accurately targeting the radiation area, so the marks should be left in place until the treatment course is complete.
B. Protecting the skin from sunlight exposure is crucial, as the irradiated skin is more sensitive and at increased risk for sunburn. This recommendation helps to prevent further irritation and damage to the skin during and after treatment.
C. While moisturizing lotions can be beneficial for maintaining skin integrity, they should be used cautiously and only if prescribed by the healthcare provider, as some products may cause irritation.
D. The skin inside the radiation portal site should be washed gently with mild soap and water to keep it clean; avoiding washing is not advisable as it can lead to skin breakdown.