During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution?

Correct Answer: D

Rationale: Notify the physician and prepare for surgery' follows evisceration. Intestines out e.g., 5 cm needs OR e.g., 100% urgent unlike 'document' , later e.g., post-action. 'Reinforce' delays e.g., not enough. 'Pain meds' secondary e.g., not fix. A nurse acts e.g., Call MD, prep' per protocol, a physiological emergency. The text mandates this, making the correct, next step.

Correct Answer: A

Rationale: Repositioning every hour is the correct answer as it helps redistribute pressure, reducing the risk of pressure ulcer formation. This action prevents prolonged pressure on specific areas, improving blood flow and tissue oxygenation. Providing a low-protein diet (B) is incorrect as protein is essential for wound healing. Ensuring a generous fluid intake (C) is important for overall skin health but alone does not prevent pressure ulcers. Massaging reddened areas on the sacrum (D) can actually worsen skin damage by increasing friction and pressure on vulnerable skin.

Correct Answer: C

Rationale: The correct answer is C: Impaired physical mobility. Impaired physical mobility can lead to pressure ulcers and skin breakdown due to prolonged pressure on specific areas. This etiology directly impacts skin integrity. Noncompliance with turning schedule (A) can contribute to skin breakdown but is not the primary etiology. Poor nutritional intake (B) can affect wound healing but is not directly related to skin integrity. Impaired adjustment (D) is not a recognized etiology for impaired skin integrity.

Correct Answer: A

Rationale: The purpose of a wet-to-dry dressing is to mechanically debride the tissue, which involves removing dead or infected tissue through the physical action of the dressing. First, the wet dressing helps to soften and loosen the necrotic tissue. Then, as the dressing dries, it adheres to the dead tissue and upon removal, it pulls the debris away, promoting a clean wound bed. This process facilitates wound healing by promoting tissue regeneration. Other choices are incorrect because reducing local tissue maceration and preventing bacterial growth are not the primary purposes of a wet-to-dry dressing. Additionally, preserving granulation tissue is not the intended goal of this dressing method.

Correct Answer: B

Rationale: The presence of an incision increases the client's susceptibility to infection as it provides a direct entry point for pathogens. A breach in the skin barrier increases the risk of microbes entering the body and causing infection. Intact mucous membranes help protect against pathogens, making choice A incorrect. Dry skin may increase the risk of skin breakdown but does not directly impact susceptibility to infection. Active bowel sounds are indicative of bowel function and do not directly relate to susceptibility to infection, making choice D incorrect.