A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Obtain a sample of the drainage to send to the laboratory.
Auscultate the abdomen for bowel sound activity.
Prepare the client to return to the operating room.
Bring additional sterile dressing supplies to the room.
The Correct Answer is C
A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.
B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.
C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.
D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.
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Correct Answer is C
Explanation
A. Oxycodone is an opioid analgesic used for moderate to severe pain management but is not typically the first-line medication in acute coronary syndrome scenarios.
B. Fentanyl is a potent opioid that may be used for severe pain; however, morphine is more commonly used in emergency situations for chest pain related to potential myocardial infarction.
C. Morphine is commonly used in emergency departments for the management of acute chest pain, particularly when associated with myocardial ischemia. It helps reduce pain and anxiety, lowers myocardial oxygen demand, and has vasodilatory effects that can alleviate the burden on the heart.
D. Hydromorphone is another opioid analgesic but is not usually the preferred choice for chest pain in the acute setting compared to morphine.
Correct Answer is A
Explanation
A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.
B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.
C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.
D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.