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 A
Explanation
A) Gently elevate the client's head and note any nuchal rigidity: This action is crucial for assessing for meningeal irritation, which is a common sign of bacterial meningitis. Nuchal rigidity refers to stiffness in the neck that makes it difficult for the client to flex their neck forward. This sign, along with other symptoms, can help confirm the suspicion of meningitis.
B) Strike the client's patellar tendon with a percussion hammer and note any increase in response: While assessing deep tendon reflexes can provide information about neurological function, it is not specific to meningitis. Increased reflex response may not
directly indicate meningeal irritation.
C) Tap the client's facial nerve and note any facial twitching: This action is not a standard assessment for bacterial meningitis. Facial twitching could indicate other neurological issues but is not specifically related to meningitis.
D) Run a tongue blade on the outside of the client's sole and note any flaring of the toes: This action describes the Babinski reflex, which is not a typical assessment for meningitis. It may indicate upper motor neuron lesions but does not specifically assess for meningitis.
Correct Answer is D
Explanation
A) "It is normal to feel this way after a morning run.": While some fatigue can be expected after exercise, the client's symptoms of diaphoresis, palpitations, and exhaustion suggest that there may be an underlying issue related to their diabetes management, such as hypoglycemia. This response downplays the seriousness of their symptoms.
B) "It becomes easier when exercise is a routine.": While it is true that regular exercise can improve fitness and make physical activity feel easier over time, this response does not address the immediate concern of the client's current symptoms, which could indicate hypoglycemia.
C) "Were you careful to not have carbohydrates after the run?": This response suggests a misunderstanding of the client's needs. After exercise, especially for someone with type 1 diabetes, it is important to ensure adequate carbohydrate intake to prevent hypoglycemia. The client may need carbohydrates rather than avoiding them.
D) "Did you decrease your insulin intake before you exercised?": This is the most appropriate response. Clients with type 1 diabetes need to manage their insulin levels carefully, especially around exercise. If the client did not adjust their insulin dose or carbohydrate intake appropriately, they could be at risk for hypoglycemia, which explains their symptoms. This question encourages the client to reflect on their diabetes management in relation to their exercise.