👉 Wound evisceration is a life-threatening surgical emergency in which the abdominal incision separates, allowing internal organs (usually the intestines) to protrude through the wound.

👉 The nurse's highest priority is to protect the exposed abdominal organs from injury, drying, and contamination while preparing the client for emergency surgery.

👉 Sterile dressings moistened with sterile normal saline keep the exposed organs moist, preventing tissue dehydration (desiccation), which can rapidly damage the bowel.

👉 Moist sterile dressings also reduce the risk of infection by protecting the exposed organs from environmental contaminants.

👉 After covering the organs, the nurse should notify the surgeon or rapid response/surgical team immediately, as the client requires prompt surgical repair.

👉 The nurse should position the client in low Fowler's position with knees slightly flexed (or supine with knees bent according to facility policy) to decrease tension on the abdominal incision and reduce further protrusion.

👉 The nurse should keep the client NPO, monitor vital signs, provide reassurance, and prepare for emergency surgery while continuing to assess for signs of shock.

👉 Therefore, covering the protruding organs with a sterile saline-moistened dressing and immediately notifying the surgical team is the priority intervention because it protects the organs while definitive treatment is arranged.

❌ Encourage the client to lie flat and bear down to reduce the protrusion while awaiting provider instructions.

👉 Bearing down (Valsalva maneuver) significantly increases intra-abdominal pressure, which can worsen the evisceration and force more abdominal contents through the incision.

👉 The nurse should instruct the client not to cough, strain, or bear down, and should never attempt to have the client reduce the protrusion independently.

❌ Administer prescribed analgesics to manage pain before assessing the wound further.

👉 Although pain control is important, protecting the exposed organs and obtaining emergency surgical intervention take priority over pain management.

👉 Assessment and protection of the wound should occur immediately, with analgesics administered after emergency measures have been initiated if appropriate.

❌ Apply direct pressure to the site to stop any bleeding before notifying the provider.

👉 Direct pressure should never be applied to protruding abdominal organs, as it can damage delicate tissues, impair blood flow, and increase the risk of further injury.

👉 The correct intervention is to gently cover the organs with sterile saline-moistened dressings without attempting to push them back into the abdomen.

👉 Septic shock develops from a severe systemic response to infection, leading to profound vasodilation, impaired tissue perfusion, cellular dysfunction, and potentially multiple organ failure.

👉 The client has a known urinary tract infection (UTI), providing an active infectious source that can spread into the bloodstream and progress to sepsis.

👉 Urinary tract infections are a common source of urosepsis, especially in clients with weakened immune systems or other serious health conditions.

👉 The client is receiving chemotherapy, which can suppress bone marrow function and decrease the production of infection-fighting white blood cells.

👉 Chemotherapy can cause neutropenia, significantly reducing the client's ability to contain and fight an infection before it becomes systemic.

👉 A temperature of 101.8°F (38.8°C) indicates fever, which is an important sign of infection in an immunocompromised client and requires immediate evaluation.

👉 The combination of active infection + immunosuppression + fever places this client at substantially greater risk for rapid progression from infection to sepsis and septic shock.

👉 Therefore, the client receiving chemotherapy who has a UTI and fever is at the greatest risk for developing septic shock and requires immediate assessment and intervention.

❌ A client who developed hives after taking a newly prescribed antibiotic.

👉 Hives following antibiotic administration suggest an allergic reaction, which can progress to anaphylaxis and distributive shock if severe.

👉 However, this client does not have evidence of a severe systemic infection, so the primary concern is anaphylactic shock rather than septic shock.

❌ A client who experienced major blood loss following a motor vehicle collision.

👉 Major blood loss causes decreased circulating blood volume and places the client at risk for hypovolemic shock.

👉 Although this is a serious emergency, the mechanism is hemorrhage rather than infection, so it does not represent the greatest risk for septic shock.

❌ A client with severe dehydration related to vomiting and diarrhea.

👉 Severe dehydration reduces circulating blood volume and can lead to hypovolemic shock if fluid losses are not corrected.

👉 The client's shock risk is related to fluid depletion rather than a systemic infectious process, making septic shock less likely.

👉 Erythema (redness) around a surgical wound is a classic sign of inflammation and may indicate infection when it is increasing, spreading, or accompanied by other abnormal findings.

👉 Increased warmth or heat occurs because the inflammatory response causes vasodilation and increased blood flow to the infected tissue.

👉 Edema (swelling) develops due to increased capillary permeability, which allows fluid and inflammatory cells to accumulate in the surrounding tissues.

👉 Purulent drainage is thick drainage containing leukocytes, microorganisms, and cellular debris, and is a strong indicator of bacterial wound infection.

👉 The combination of redness, warmth, swelling, and purulent drainage represents classic local manifestations of an infected surgical wound.

👉 The nurse should further assess for systemic manifestations of infection, including fever, chills, increasing pain, malaise, tachycardia, and an elevated white blood cell count.

👉 An infected surgical wound requires prompt reporting, wound assessment, possible wound culture, and antimicrobial therapy as prescribed to prevent progression to cellulitis, abscess formation, sepsis, or delayed wound healing.

👉 Therefore, erythema, heat, edema, and purulent drainage are the findings most clearly indicating a surgical wound infection.

❌ There is an overgrowth of whitish collagen and serous fluid.

👉 Collagen formation is part of the normal proliferative phase of wound healing, while small amounts of clear or pale-yellow serous drainage can be expected.

👉 These findings alone do not indicate infection, especially without purulent drainage, spreading erythema, increasing warmth, or worsening pain.

❌ Copious amounts of serosanguineous fluid.

👉 Serosanguineous drainage is a thin, watery mixture of serum and small amounts of blood that can occur during normal early wound healing, although copious drainage requires further assessment.

👉 Excessive drainage may indicate a wound complication such as bleeding or dehiscence, but it is not as specific for infection as purulent drainage with redness, warmth, and swelling.

❌ Wound looks irregular, raised, and purplish.

👉 An irregular, raised wound may indicate abnormal scar formation, such as a hypertrophic scar or keloid, rather than an active infection.

👉 The absence of classic infectious findings such as purulent drainage, increasing warmth, erythema, and edema makes this option less consistent with a surgical wound infection.

👉 Furosemide is a loop diuretic that acts on the ascending loop of Henle to increase the excretion of sodium and water.

👉 Furosemide also causes increased urinary potassium loss, placing the client at significant risk for hypokalemia.

👉 Before administering scheduled furosemide, the nurse should review the client's serum potassium level to determine whether the medication can be given safely.

👉 A normal serum potassium level is approximately 3.5 to 5 mEq/L, and a potassium level below the expected range should be reported because furosemide can worsen the deficiency.

👉 Hypokalemia can cause muscle weakness, fatigue, leg cramps, constipation, and decreased intestinal motility.

👉 Severe hypokalemia can cause dangerous cardiac dysrhythmias, making potassium monitoring a major safety priority when administering loop diuretics.

👉 The risk becomes especially important if the client is also taking digoxin, because hypokalemia increases the client's susceptibility to digoxin toxicity and dysrhythmias.

👉 Therefore, after assessing the client's vital signs, the nurse should review the potassium level before administering scheduled furosemide to prevent serious electrolyte and cardiac complications.

❌ Respiratory rate

👉 Respiratory rate is an important component of routine assessment, but it is not the key medication-specific parameter associated with furosemide administration.

👉 Furosemide does not routinely cause respiratory depression; the major concerns include hypotension, dehydration, electrolyte loss, and particularly hypokalemia.

❌ Urinary osmolality

👉 Urinary osmolality measures the concentration of dissolved particles in the urine and may be useful when evaluating renal function and fluid balance disorders.

👉 It is not routinely the priority laboratory value reviewed before administering scheduled furosemide; serum electrolytes, particularly potassium, are more clinically relevant.

❌ Hematocrit level

👉 Hematocrit reflects the percentage of red blood cells in the blood and can provide information about anemia, bleeding, or hemoconcentration.

👉 Although excessive diuresis and dehydration can potentially increase hematocrit, it is not the priority value to review before administering furosemide.

👉 Hypernatremia is defined as a serum sodium concentration greater than 145 mEq/L.

👉 The expected normal serum sodium range is approximately 135 to 145 mEq/L, so values above this range indicate an excess concentration of sodium relative to water.

👉 Hypernatremia commonly develops because of water loss, inadequate water intake, excessive sodium intake, or disorders that increase free-water excretion, such as diabetes insipidus.

👉 An elevated sodium concentration causes water to move out of the intracellular space and into the extracellular space through osmosis, resulting in cellular dehydration.

👉 Brain cells are particularly sensitive to cellular dehydration, so neurologic manifestations such as restlessness, irritability, confusion, muscle twitching, seizures, and coma can occur.

👉 Clients with hypernatremia may also exhibit intense thirst, dry mucous membranes, weakness, and decreased urine output, depending on the underlying cause and fluid status.

👉 Nursing management includes monitoring neurologic status, fluid balance, intake and output, daily weight, and serum sodium levels, while correcting the underlying cause and administering fluids as prescribed.

👉 Therefore, a serum sodium concentration greater than 145 mEq/L indicates hypernatremia and requires further assessment and appropriate management.

❌ Less than 135 mEq/L

👉 A serum sodium concentration below 135 mEq/L indicates hyponatremia, not hypernatremia.

👉 Hyponatremia can cause neurologic manifestations such as headache, confusion, seizures, and decreased level of consciousness because water moves into brain cells.

❌ Less than 3.5 mEq/L

👉 A value below 3.5 mEq/L refers to hypokalemia, because the normal serum potassium range is approximately 3.5 to 5 mEq/L.

👉 This value does not indicate a sodium imbalance and may cause muscle weakness, decreased gastrointestinal motility, and cardiac dysrhythmias.

❌ Greater than 5.0 mEq/L

👉 A value above 5.0 mEq/L refers to hyperkalemia, which is an elevated serum potassium concentration.

👉 Hyperkalemia is especially concerning because it can cause muscle weakness and potentially life-threatening cardiac dysrhythmias.

🚽 Urine output (indwelling catheter):

0800: 400 mL

1200: 450 mL

End of shift drainage bag: 700 mL

Total urine = 400 + 450 + 700 = 1,550 mL

🤮 Vomiting (emesis):

Clear emesis = 300 mL

🩹 Jackson-Pratt (JP) drain:

Drainage = 15 mL

Total Output:

1,550 mL + 300 mL + 15 mL = 1,865 mL

👉 A 7-month-old infant with a severe airway obstruction who cannot cry or cough requires immediate intervention because the airway is completely blocked.

👉 Since the infant is conscious but unable to produce effective sounds or cough, the nurse should perform infant choking maneuvers immediately.

👉 For infants younger than 1 year, the recommended first action is five back blows followed by five chest thrusts.

👉 Back blows are delivered between the infant’s shoulder blades while the infant is positioned face-down with the head lower than the chest.

👉 If the object is not expelled, the nurse turns the infant face-up and performs five chest thrusts using two fingers on the sternum.

👉 The cycle of five back blows and five chest thrusts is repeated until the object is removed or the infant becomes unresponsive.

👉 Abdominal thrusts (Heimlich maneuver) are not performed on infants under 1 year because they can injure internal organs.

👉 Therefore, because the infant is conscious and has a severe airway obstruction, the nurse should immediately perform five back blows followed by five chest thrusts.

❌ Sweep the infant's mouth with a finger to remove the object.

👉 Blind finger sweeps should not be performed because they can push the object deeper into the airway.

👉 The nurse should only remove the object if it is clearly visible and easily accessible.

❌ Begin rescue breathing immediately.

👉 Rescue breathing is performed when the infant becomes unresponsive or after the airway obstruction has been relieved and breathing does not resume.

👉 A conscious infant with severe choking requires foreign body removal maneuvers first, not ventilation.

❌ Perform abdominal thrusts until the object is expelled.

👉 Abdominal thrusts are not recommended for infants younger than 1 year because their abdominal organs are vulnerable to injury.

👉 Infants require back blows and chest thrusts, not the Heimlich maneuver.

👉 The head-tilt/chin-lift maneuver is the primary technique used to open the airway in an unconscious or collapsed patient when there is no suspicion of cervical spine injury.

👉 When a person becomes unconscious, the tongue can relax and fall backward, blocking the airway and preventing air movement.

👉 The head-tilt/chin-lift maneuver works by tilting the head backward and lifting the chin upward, which moves the tongue away from the posterior pharynx.

👉 Opening the airway is the first step in assessing and managing a collapsed patient because airway obstruction can quickly lead to inadequate oxygenation and cardiac arrest.

👉 The nurse should perform the maneuver while assessing for normal breathing and signs of airway obstruction.

👉 If the patient is not breathing normally, the nurse should proceed with appropriate basic life support interventions, including rescue breathing and chest compressions as indicated.

👉 This technique is preferred because it is simple, rapid, and effective in restoring airway patency in most collapsed patients.

👉 Therefore, the nurse should use the head-tilt/chin-lift maneuver to open the airway of a collapsed patient with a possible blocked airway.

❌ Chest compressions

👉 Chest compressions are used to circulate blood during cardiac arrest, not to directly open the airway.

👉 They may be required if the patient has no pulse or is not breathing normally, but airway opening comes first during initial assessment.

❌ Abdominal thrusts

👉 Abdominal thrusts are used to treat a conscious patient with a severe choking obstruction, particularly adults and children older than 1 year.

👉 They are not the first technique used simply to open the airway of a collapsed patient.

❌ Logroll

👉 A logroll is a technique used to move a patient while maintaining spinal alignment, especially when spinal injury is suspected.

👉 It does not open the airway and is not an immediate airway management technique.