Upon entering a client's room, a nurse finds that the abdominal ...

[Frost2351]

Upon entering a client's room, a nurse finds that the abdominal surgical wound has eviscerated. The nurse should:
 
  A. Call for help
  B. Sit the client upright
  C. Attempt to replace the organs
  D. Cover the site with saline-soaked sterile gauze

Question 2

After teaching a home caregiver how to mange a pressure ulcer, the nurse realizes further education is needed when the caregiver says:
 
  A. I will be sure to reposition her frequently and keep her off of the pressure ulcer.
  B. I will wash the pressure ulcer with saline and report any changes in the drainage.
  C. I know that a thick, black covering will protect the pressure ulcer from getting worse.
  D. I will let you know if the pressure ulcer starts to smell rotten.

[234sdffa]

Answer to Question 1

D
D. Report wound dehiscence and/or evisceration to surgeon immediately because it could be life threatening. If evisceration has occurred, cover abdominal contents with sterile gauze saturated with sterile normal saline and prepare client for emergency surgery.
A. Cover site and call for help.
B. Keep client flat.
C. If evisceration has occurred, cover abdominal contents with sterile gauze saturated with sterile normal saline and prepare client for emergency surgery.

Answer to Question 2

C
C. Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment.
A. This statement indicates the caregiver understands the factors
that cause pressure ulcers.
B. This statement indicates that the caregiver understands how to cleanse and assess the pressure ulcer.
D. This statement indicates that the caregiver understands a warning sign of infection of the pressure ulcer.

[Frost2351]

Gracias!

[sailorcrescent]

TYSM