ATI RN
ATI Fundamentals 100 Exam 4 Questions
Extract:
Question 1 of 5
The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Apply a sterile normal saline dressing. This intervention should be implemented first to protect the exposed abdominal organs from injury and contamination. By covering the evisceration with a sterile dressing soaked in normal saline, the nurse can prevent infection and maintain a moist environment for optimal wound healing. It is crucial to prioritize protecting the client's health and safety in this emergency situation.
Other choices are incorrect because:
B: Using sterile gloves to replace the protruding parts can cause further trauma and should not be done without medical supervision.
C: Administering IV antibiotics STAT may be necessary, but it is not the first priority in managing evisceration.
D: Placing the client in reverse Trendelenburg position does not address the immediate need to protect the exposed organs.
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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