RN Tissue Integrity: Wound Evisceration 3.0 Case Study Test

a nurse is teaching a client who is postoperative following abdominal surgery. which of the following instructions should the nurse include to reduce the risk for wound evisceration? "Perform leg exercises at frequent intervals." "Use an incentive spirometer every hour while awake." Turn side to side every 2 hours." "Support your abdomen with a pillow when coughing."

"Support your abdomen with a pillow when coughing." The nurse should instruct the client to support their abdomen with a pillow when coughing to provide support to the incision and reduce the risk for wound evisceration.

a nurse is caring for four clients who are 4 days postoperative following abdominal surgery. the nurse should further asses which of the following clients for a wound evisceration? A client who states that they are passing flatus A client who reports feeling their incision separate when they sneezed A client who has serous drainage on the wound dressing A client who has bruising around the incision

A client who reports feeling his incision separate when he sneezed The nurse should assess this client for wound dehiscence or evisceration. A wound evisceration can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from forceful coughing, sneezing, or vomiting. Clients often report feeling something has "popped" or opened in the wound.

a nurse is assessing a client who is postoperative following abdominal surgery and discovers bowel protruding from the clients incision. which of the following actions should the nurse take first? Contact the rapid response team. The greatest risk to this client is compromised blood supply to the bowel resulting in necrosis; therefore, the first action the nurse should take is to contact the rapid response team for immediate assistance. Check the client for shock The nurse should check the client for manifestations of shock, such as tachycardia and hypotension; however, it is not the first action the nurse should take. Document the incident. The nurse should document the incident to communicate the sequence of events to other members of the health care team to ensure comprehensive and effective care for the client; however, it is not the first action the nurse should take. Prepare the client for surgery. The nurse should prepare the client for surgery to repair the evisceration; however, it is not the first action the nurse should take.

Contact the rapid response team. The greatest risk to this client is compromised blood supply to the bowel resulting in necrosis; therefore, the first action the nurse should take is to contact the rapid response team for immediate assistance.

a nurse is assessing a client who is postoperative following abdominal surgery and discovers the client has bowl protruding from the incision. which of the following actions should the nurse take? Place the client in high-Fowler's position. To reduce abdominal muscle strain, the nurse should place the client in a supine position with the knees flexed. Reinsert the protruding bowel. Reinserting the protruding bowel can result in injury to the client. Cover the wound with a nonadherent dressing. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile 0.9% sodium chloride to protect the wound from infection and further injury. Straighten the client's legs. The nurse should bend the client's knees to reduce the strain on the client's incision and prevent further evisceration.

Cover the wound with a nonadherent dressing.

a nurse is assessing a client who is postoperative following abdominal surgery. the nurse should identify that which of the following findings increases the client's risk for wound evisceration? The client is morbidly obese. The client has decreased bowel sounds. The client has an NG tube to provide continuous suction.

The client is morbidly obese. A client who is morbidly obese has an increased risk for wound dehiscence and evisceration due to excessive strain to the suture line. The nurse should instruct the client to support the incision when moving to reduce the risk for evisceration.