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) Remind the client of the importance of medication adherence.: While emphasizing medication adherence is important, it does not directly advocate for the client's needs related to self-care at home. It is more of a standard teaching point rather than a specific action to support the client's independence.
B) Tell the client to avoid places where there are large crowds of people.: Advising the client to avoid crowded places is a precaution to prevent infection, but it does not empower the client or help them maintain their self-care abilities. Advocacy involves supporting the client's choices and helping them navigate their circumstances.
C) Initiate a referral for the client to a home health agency.: This action demonstrates client advocacy by actively seeking resources that can provide the client with the support they need to manage their care at home. A home health agency can offer assistance with medication management, monitoring health status, and providing companionship, which aligns with the client's goal of self-care while living alone.
D) Instruct the client to avoid eating raw vegetables.: While this is a valid dietary recommendation for someone with a compromised immune system, it does not specifically advocate for the client’s self-care or independence. It is a preventive measure rather than a supportive action that empowers the client.
Correct Answer is A
Explanation
A) Assess urine output hourly. Monitoring urine output hourly is critical in the postoperative care of a client following a kidney transplant. It helps assess kidney function and detect any potential complications such as acute rejection or acute tubular necrosis early. Changes in urine output can provide important information about the client's fluid status and renal perfusion.
B) Check the client's blood pressure every 8 hr. While monitoring blood pressure is important, it is not sufficient to check it only every 8 hours in the immediate postoperative period. Blood pressure can fluctuate significantly due to factors such as fluid status, medication effects, and potential complications. More frequent monitoring, especially in the first 24 hours, is essential for timely intervention.
C) Monitor for hypokalemia as a manifestation of acute rejection. Hypokalemia is not typically a manifestation of acute rejection following a kidney transplant; rather, hyperkalemia is more commonly observed due to impaired kidney function. Therefore, focusing on monitoring for signs of hyperkalemia would be more relevant in this context.
D) Administer opioids PO. While pain management is crucial after surgery, opioids are often administered intravenously in the immediate postoperative period for better control and quicker action. Oral administration may be appropriate later when the client is stable and can tolerate oral medications.