Which of the following nursing interventions would be appropriate after a wound evisceration?
1. Place the client in high-Fowler's position.
2. Give the client fluids to prevent shock.
3. Push the organs back inside and tape up the wound.
4. Apply a sterile saline-soaked dressing and cover.
4
The nurse is to cover the wound with a sterile saline-soaked dressing and maintain it until the client is taken to surgery. High-Fowler's position will not help with wound evisceration. Providing fluids would be contraindicated since the client will be returning to surgery. The nurse should not manipulate the exposed organs.
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When assessing the gastrointestinal system, the order of assessment progresses in which of the following ways?
a. Inspection, palpation, percussion, auscultation b. Palpation, percussion, inspection, auscultation c. Inspection, auscultation, percussion, palpation d. Palpation, inspection, auscultation, percussion
Which would be the priority nursing intervention for a child who has been involved in an automobile collision and is now a paraplegic?
1. Develop and implement a teaching plan. 2. Discuss improvement for family coping. 3. Contact the family clergy for support. 4. Arrange for the child's friends to visit.
The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?
a. Keep the tube clamped. b. Suction the tube as needed. c. Leave the tube open to gravity drainage. d. Lower the tube to a point below the level of the stomach.
A nurse is preparing oral medications for administration. Which of the following should the nurse do when preparing these medications?
a. When preparing liquids, pour the liquid from the bottle to the patient's mouth. b. Remove unit dose drug from wrapper before getting to the bedside. c. Prepare liquids by placing the label side of the bottle on the outside away from the hand. d. Check the patient's armband before administering the medications.