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) "Apply a second pair of gloves before touching the client's implant if it dislodges.": This is the correct action. If a sealed radiation implant dislodges, the nurse should wear a second pair of gloves to minimize exposure to radiation while handling the implant. This is a crucial safety measure to protect both the nurse and others in the environment.
B) "Limit family member visits to 30 min per day.": While it is important to limit the time family members spend with a patient who has a sealed radiation implant, the specific duration can vary based on institutional policies and the level of radiation. It may not be necessary to restrict visits to exactly 30 minutes.
C) "Give the dosimeter badge to the oncoming nurse at the end of the shift.": The dosimeter badge should not be passed to another nurse. Each nurse should wear their own badge to accurately measure their individual exposure to radiation. It should be kept by the individual nurse throughout their shifts.
D) "Remove soiled linens from the room after each change.": This statement is misleading. Soiled linens should be handled with care and may need to be treated as radioactive waste depending on the facility's protocols. They should not be removed without following proper safety and disposal guidelines.
Correct Answer is C
Explanation
A) Administer aspirin: While administering aspirin is important in the management of acute angina to inhibit platelet aggregation, it is not the immediate priority. Aspirin helps prevent further clot formation but does not relieve the acute symptoms of angina.
B) Initiate IV access: Establishing IV access may be necessary for medication administration, but it should not be the first action taken when a client is experiencing acute angina. Immediate relief of chest pain is the priority.
C) Administer nitroglycerin: This is the first action the nurse should take. Nitroglycerin acts quickly to relieve angina by dilating coronary arteries, thus improving blood flow to the heart muscle. Relief of pain and ischemia is the immediate priority.
D) Measure blood pressure: While monitoring vital signs is crucial, especially in a client with cardiac issues, the most urgent intervention in the context of acute angina is pain relief. Blood pressure may be assessed after administering nitroglycerin since it can affect hemodynamics.