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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View Related questions
Correct Answer is A
Explanation
Rationale:
A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.
B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.
C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.
D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.
Correct Answer is D
Explanation
Rationale:
A. After a bowel preparation, it typically takes a few days for fecal output to occur from the new colostomy due to the emptying of the bowel before surgery.
B. Increasing raw vegetables immediately after surgery is not recommended, as they can cause gas and irritation to the bowel. Clients are usually advised to start with low-fiber foods and gradually introduce more fiber.
C. A healthy stoma should be pink to red in color. A purplish color may indicate compromised blood flow and should be reported to the healthcare provider.
D. A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the appliance, as the tissue is delicate and highly vascular.