What is Nurse Trish’s first response to wound dehiscence with evisceration after a colon resection?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Nurse Trish's first response should be to cover the wound with a saline-soaked sterile dressing to prevent infection and keep the exposed tissues moist. 2. This action helps protect the wound and organs from further damage or contamination. 3. It is important to maintain the sterility of the dressing to minimize the risk of infection. 4. Calling the physician can be the next step after stabilizing the wound with the dressing. 5. Taking blood pressure and pulse is important but not the immediate priority in this situation. 6. Pulling the dehiscence closed is contraindicated as it can cause further harm and should not be attempted by the nurse.

Correct Answer: A

Rationale: The correct answer is A: Keep a closed sterile drainage system. This is crucial to prevent infection by maintaining a closed system, reducing the risk of introducing bacteria into the bladder. The closed system prevents ascending infection. Choice B is incorrect because routine catheter irrigation can introduce pathogens into the bladder. Choice C is incorrect because keeping the bag lower than the bed can lead to reflux of urine back into the bladder, increasing the risk of infection. Choice D is incorrect because while measuring intake and output is important for monitoring fluid balance, it is not a direct safety measure for catheter care.

Correct Answer: D

Rationale: The correct answer is D because it follows the PES format, which stands for Problem (nursing diagnosis), Etiology (related factor), and Signs/Symptoms (defining characteristics). In this case, the Problem is "Self-esteem disturbance," the Etiology is "related to rejection by the husband," and the Signs/Symptoms are "manifested by crying and isolation." The other options do not follow the PES format correctly. A lacks defining characteristics, B does not have a clear related factor, and C does not have a problem clearly identified. Thus, D is the correct choice as it adheres to the PES structure for nursing diagnosis formulation.

Correct Answer: C

Rationale: The correct answer is C: Gauge. The gauge refers to the thickness of the needle itself and is not a part of the needle. The hub is where the needle attaches to the syringe, the shaft is the long portion of the needle, and the bevel is the slanted tip for easier insertion. Gauge is a measurement of the needle's thickness and is not a physical component of the needle itself. Therefore, option C is the correct answer.

Correct Answer: D

Rationale: The lab values indicate a high WBC count (12,000/mm3) suggesting an elevated immune response, typical in infections. The RBC count (5M/mm3) and platelet count (200,000/mm3) are within normal range ruling out dehydration and polycythemia. The prothrombin time of 11 seconds is also normal. Therefore, the most likely interpretation is an infection. Dehydration would show high RBC count and high platelet count, polycythemia would show high RBC count, and leukopenia would show low WBC count.