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 B
Explanation
A) Check pressure points every 12 hr.: This action is insufficient frequency for a client in skeletal traction. Pressure points should be assessed more frequently, ideally every 2 hours, to prevent skin breakdown and complications related to immobility.
B) Provide the client with a trapeze bar.: This is the most appropriate action. A trapeze bar allows the client to assist with repositioning themselves and helps to reduce strain on the muscles and joints, promoting better mobility while in traction.
C) Instruct the client to use their elbows to reposition.: While this might help the client move slightly, using the elbows alone could lead to strain and discomfort. Proper use of a trapeze bar is a better approach to support safe and effective repositioning.
D) Remove the weights before changing the client's bed linens.: Weights should never be removed without a healthcare provider's order as this can disrupt the alignment and effectiveness of the skeletal traction, potentially causing complications.
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.