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) "I can assist you with making a list of foods you like for the dietitian.": This statement encourages the client to take an active role in their dietary management by involving them in the process of planning their meals. It fosters collaboration and empowers the client to express their preferences, making it more likely they will adhere to the dietary recommendations.
B) "I understand that the dietary choices can seem overwhelming.": While this statement acknowledges the client's feelings, it does not actively promote their involvement in the care plan. It reflects empathy but lacks the encouragement needed for the client to engage in managing their diabetes.
C) "Managing your diabetes will require you to make accommodations.": This statement emphasizes the need for change but may come across as directive and could potentially discourage the client. It doesn't foster a sense of partnership in the decision-making process.
D) "The dietitian will provide you with the best food choices to manage your diabetes.": Although this statement highlights the dietitian's expertise, it places the responsibility solely on the dietitian and does not encourage the client to participate in their own dietary decisions. Engaging the client in the conversation is key to enhancing their motivation and compliance.
Correct Answer is D
Explanation
A) "I will increase my intake of canned vegetables.": This statement indicates a lack of understanding. Canned vegetables can be high in sodium, which is not advisable for individuals with cardiovascular disease. Fresh or frozen vegetables are usually better options.
B) "I will drink whole milk with my cereal.": Whole milk is higher in saturated fat and cholesterol, which can contribute to cardiovascular issues. Low-fat or non-fat milk would be a more appropriate choice for someone with cardiovascular disease.
C) "I will limit my portions of meat to 8 ounces.": While portion control is important, this statement does not reflect an understanding of the type of meat to consume. It’s not just about the portion size but also about choosing lean meats and limiting red and processed meats.
D) "I will use canola oil when making salad dressing.": This statement shows an understanding of dietary recommendations for cardiovascular health. Canola oil is a healthier choice due to its lower saturated fat content and higher levels of heart-healthy monounsaturated fats, making it a better option for someone managing cardiovascular disease.