ATI RN
ATI RN Capstone Proctored Comprehensive Assessment Exam A Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like 'something opened up.' The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct action for the nurse to take in this scenario is to cover the wound with a saline-soaked dressing (
Choice
C). This is based on the principle of protecting the exposed tissue from contamination and preventing further complications such as infection. By covering the wound with a saline-soaked dressing, the nurse can create a moist environment that can help promote healing and reduce the risk of infection. Reinserting the protruding intestinal tissue (
Choice
A) should not be done by the nurse, as this is a medical intervention that should be performed by a healthcare provider. Placing the client in Trendelenburg position (
Choice
B) is not necessary and may not address the primary concern of wound separation. Monitoring vital signs every 30 minutes (
Choice
D) is important but not the immediate priority when there is protrusion of intestinal tissue.
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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