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. While sipping fluids with meals can help prevent discomfort, it is generally recommended to avoid drinking fluids during meals to minimize the risk of overfilling the stomach.
B. Reducing intake of fatty foods is important, but it is not as critical as managing portion sizes and meal frequency after gastric bypass surgery.
C. Eating small frequent meals is crucial after gastric bypass surgery because it helps manage the reduced stomach capacity and promotes better nutrient absorption while preventing dumping syndrome and discomfort.
D. Chewing slowly and thoroughly is a good practice to aid digestion, but it is not as essential as the need for portion control and meal frequency following the surgery.
Correct Answer is B
Explanation
A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.
B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.
C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.
D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.