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.
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Correct Answer is D
Explanation
Rationale:
A. Cold fluids are less effective in stimulating bowel movements compared to warm fluids. Warm fluids tend to promote peristalsis and help relieve constipation, making cold fluids a less appropriate option.
B. A low-fiber diet would worsen constipation. High-fiber foods are more effective in promoting bowel regularity by adding bulk to the stool, facilitating easier passage.
C. Mineral oil is not a first-line treatment for constipation due to the risk of nutrient malabsorption and potential complications like aspiration in bedridden clients. It should be used cautiously.
D. Increasing fluid intake is an essential intervention for constipation, especially for clients on bedrest. Proper hydration softens stools and helps in promoting bowel movements, reducing the risk of constipation.
Correct Answer is D
Explanation
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.