A patient has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:
A) Call the physician.
B) Place saline-soaked sterile dressings on the wound.
C) Take a blood pressure and pulse.
D) Pull the dehiscence closed.
Ans: B
Chapter: 20
Cognitive Level: Analysis
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-4
Feedback: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patient's vital signs. The dehiscence needs to be surgically closed; the nurse should never try to close it.
You might also like to view...
Which section of the report allows a nurse researcher to review reduction of data in the form of tables and figures?
a. Results b. Discussion c. Literature review d. Methods
A religion that began in Scotland and evolved from John Calvin in the sixteenth century is known as
a. Presbyterianism. b. Episcopalian. c. Seventh-Day Adventist. d. United Church of Christ.
A 34-year-old patient was treated for a urinary tract infection (UTI) and has not responded to antibiotic therapy. Which of the following actions should be taken next?
a. Send a urine specimen for microscopy looking for fungal colonies. b. Increase the dose of antibiotic. c. Order a cytoscopy. d. Order a different antibiotic.
The hospital uses a unit-dose system for medication distribution. The nurse recognizes that this system includes which safety feature?
a. All medications are kept in the patient's drawer. b. Liquids are kept in multi-dose containers to prevent spillage. c. Narcotics are kept in an area separate from the patient's regular medications. d. The nurse is responsible for restocking the medication drawers daily.