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 monitoring blood glucose levels is important for managing diabetes, this instruction alone does not specifically address the goal of lowering blood glucose levels and increasing HDL levels.
B. Monthly appointments with a dietitian can be beneficial but are not as essential as incorporating regular exercise into the client’s lifestyle.
C. Regular exercise is a key component in managing type 2 diabetes, as it helps to lower blood glucose levels and can improve HDL cholesterol. Medical approval ensures that the exercise regimen is safe for the client.
D. Limiting calories on days unable to exercise is not a primary focus for managing diabetes and may not be practical or effective in promoting overall health.
Correct Answer is B
Explanation
A. While the use of corticosteroid cream is relevant to treatment, it does not indicate a new cause for symptom exacerbation.
B. The introduction of a new dog could be a potential allergen, triggering an exacerbation of the client's eczema symptoms.
C. Receiving an influenza immunization is unlikely to be related to eczema exacerbations and is not a common trigger.
D. An old friend with eczema does not present a direct cause for the current exacerbation and is less relevant to the client's current condition.