The nurse is caring for a patient who will have both a large ...

[BrownTown3]

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)
 
  a. Cover exposed wounds.
  b. Mark the sites of all abrasions.
  c. Assess the condition of current dressings.
  d. Inspect the skin for abrasions and edema.
  e. Cleanse the area with hydrogen peroxide.
  f. Assess the skin at underlying areas for circulatory impairment.

Question 2

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)
 
  a. Place moist sterile gauze over the site.
  b. Gently place the organs back.
  c. Contact the surgical team.
  d. Offer a glass of water.
  e. Monitor for shock.

[coreycathey]

Answer to Question 1

ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.

Answer to Question 2

ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.

[BrownTown3]

TYSM

[Jossy]

Excellent