Practice Question
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?
Answer Choices:
Correct Answer:
Prepare the client for emergency surgery.
Rationale:
🟣Evisceration is the protrusion of abdominal organs through a surgical wound, often occurring after dehiscence.
🟣This is a life-threatening emergency requiring immediate surgical repair.
🟣After applying a sterile saline-moistened dressing to maintain tissue moisture and protect against infection, the nurse must notify the surgical team and prepare the client for an urgent return to the operating room.
🟣Vital signs monitoring, NPO status, and IV access should be maintained.
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This question is from RN VATI Fundamentals S 2019 FINAL which contains 57 questions.
More Questions from This Exam
A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?
Answer Choices:
A. Encourage fluid intake of 2,500 mL/day
B. Maintain the environmental temperature at 160C to 180C (600F to 650F).
C. Immerse the client in cold water.
D. Assist the client to ambulate.
A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?
Answer Choices:
A. Apply the skin sealant on damp skin.
B. Remove the appliance before emptying the pouch.
C. Ensure that the skin is slightly damp for better adhesion of the pouch.
D. Trace the size of stoma onto the skin barrier
A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?
Answer Choices:
A. Request additional information about the caller's relationship to the client.
B. Provide a general update about the client's condition over the telephone.
C. Refer the family member to the client's provider for the update.
D. Encourage the family member to contact the client directly for information.
A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?
Answer Choices:
A. Instruct the client's loved ones that the client should not have fresh flowers in their room.
B. Wear a surgical mask when within 0.9 m (3 feet) of the client.
C. Place the client in a room with negative-airflow pressure.
D. Instruct the client that visitors will not be allowed while they are in isolation.
A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?
Answer Choices:
A. Peer pressure.
B. Death of a family member.
C. Fear of medical test results.
D. Job transfer to another city.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4
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