A nurse enters a client's room and discovers the client's abdominal incision is open with the large intestine protruding through the opening. Which of the following actions should the nurse take first?
Alert the emergency response team.
Cover the area with sterile normal saline-soaked gauze.
Place the head of the client's bed at a 15° angle.
Prepare the client for surgery.
The Correct Answer is B
A) Alert the emergency response team: While alerting the team is important, it should not be the first action taken. Immediate care to protect the client’s integrity is the priority before involving additional personnel.
B) Cover the area with sterile normal saline-soaked gauze: This is the most immediate and critical action. Covering the exposed bowel with sterile saline-soaked gauze helps to prevent infection and keeps the tissue moist, which is essential until surgical intervention can be performed.
C) Place the head of the client's bed at a 15° angle: While positioning the client can help with comfort and possibly reduce further protrusion, it is not the priority action in this emergency situation. The exposed bowel requires immediate protection.
D) Prepare the client for surgery: Preparing for surgery is a necessary step, but it should follow the immediate care for the exposed intestine. Ensuring that the bowel is covered and protected takes precedence.
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Correct Answer is C
Explanation
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.
B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.
C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.
D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good
Correct Answer is C
Explanation
A) Administer oxygen at 2 L/min: While oxygen therapy is often necessary for clients with emphysema, it should be titrated based on arterial blood gas (ABG) results and individual needs. Administering oxygen without proper assessment can lead to respiratory depression in some clients due to their reliance on hypoxic drive.
B) Encourage use of incentive spirometry for 5 min every 2 hr: Incentive spirometry is beneficial for preventing atelectasis and improving lung expansion; however, clients with emphysema may not tolerate it well due to airflow limitation. Focus should be on techniques that facilitate breathing rather than forced inhalation.
C) Teach the client a breathing exercise with a longer inhalation phase: This intervention is appropriate as it helps optimize lung function by promoting more effective gas exchange. Teaching techniques like pursed-lip breathing can help extend the exhalation phase, reducing air trapping and improving oxygenation.
D) Limit fluid intake to 1,000 mL per day: Hydration is essential for clients with emphysema to help thin secretions. Limiting fluid intake can lead to dehydration and increased viscosity of mucus, complicating respiratory efforts.