A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?
Place the client supine with knees bent.
Assess the client for manifestations of shock.
Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
Raise the head of the client's bed 15° to 20°.
The Correct Answer is C
Rationale:
A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.
B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.
C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.
D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Rationale:
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.
Correct Answer is D
Explanation
Rationale:
A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.
B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.
C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.
D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.