Asked by Margaret DiFlora on May 07, 2024
Verified
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)
A) Place moist sterile gauze over the site.
B) Gently place the organs back.
C) Contact the surgical team.
D) Offer a glass of water.
E) Monitor for shock.
Eviscerates
Refers to the removal or protrusion of internal organs through a wound or surgical incision.
Monitor for Shock
The process of observing and assessing for signs and symptoms of shock, a life-threatening condition resulting from inadequate blood flow to parts of the body.
- Detect the signs and symptoms associated with impaired skin barrier and infectious conditions.
- Acquire knowledge about the process of wound healing and the specific nursing measures needed at every stage.
Verified Answer
KD
Kendall DurrettMay 07, 2024
Final Answer :
A, C, E
Explanation :
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.
Learning Objectives
- Detect the signs and symptoms associated with impaired skin barrier and infectious conditions.
- Acquire knowledge about the process of wound healing and the specific nursing measures needed at every stage.