NCLEX-PN
Nclex 2024 Questions Questions
Extract:
Question 1 of 5
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
Correct Answer: B
Rationale: In the scenario where a client's wound eviscerates, the most appropriate nursing action is to cover the wound with a sterile saline-soaked dressing. Reinserting the protruding organ, as mentioned in choice A, is incorrect because it can lead to further complications requiring the client to return to surgery.
Choice B, covering the wound with a sterile 4x4 and ABD dressing, is not ideal as it may not provide adequate protection and moisture for the exposed tissue.
Choice D, applying an abdominal binder and manual pressure to the wound, is inappropriate as it does not address the specific needs of wound evisceration. Covering the wound with a sterile saline-soaked dressing helps maintain a moist environment, protects the exposed tissue, and prevents infection, promoting optimal wound healing and reducing the risk of complications.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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