ATI RN Medical Surgical Tissue Integrity Wound Evisceration Case Study Test 3.0 With Answers-5 Solved Questions

RN Tissue Integrity: Wound Evisceration 3.0 Case Study Test

Question: 1 of 5
A nurse is caring for four clients who are 4 days postoperative following abdominal surgery.
The nurse should further assess which of the following clients for a potential wound
evisceration?
A. Client who states that they are passing flatus
B. A client who reports feeling their incision separate when they sneezed
C. A client who has serous drainage on the wound dressing
D. A client who has bruising around the incision
Answer: B. A client who reports feeling their incision separate when they sneezed

Question: 2 of 5
A nurse is assessing a client who is postoperative following abdominal surgery and discovers
the client has bowel protruding from the incision. Which of the following actions should the
nurse take?
A. Place the client in high-Fowler’s position.
B. Reinsert the protruding bowel.
C. Cover the wound with a nonadherent dressing.
D. Straighten the client’s legs.
Answer: C. Cover the wound with a nonadherent dressing.

Question: 3 of 5
A nurse is assessing a client who is postoperative following abdominal surgery. The nurse
should identify that which of the following findings increases the client’s risk for wound
evisceration?

A. The client is morbidly obese.
B. The client has decreased bowel sounds.
C. The client has an NG tube to provide continuous suction.
D. The client has staples securing the wound.
Answer: A. The client is morbidly obese.

Question: 4 of 5
A nurse is teaching a client who is postoperative following abdominal surgery. Which of the
following instructions should the nurse include to reduce the risk for wound evisceration?
A. “Perform leg exercises at frequent intervals.”
B. “Use an incentive spirometer every hour while awake.”
C. “Turn side to side every 2 hours.”
D. “Support your abdomen with a pillow when coughing.”
Answer: D. “Support your abdomen with a pillow when coughing.”

Question: 5 of 5
A nurse is assessing a client who is postoperative following abdominal surgery and discovers
bowel protruding from the client’s incision. Which of the following actions should the nurse
take first?
A. Contact the rapid response team.
B. Check the client for shock.
C. Document the incident.
D. Prepare the client for surgery.
Answer: A. Contact the rapid response team.