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) Decorticate posturing: This is a more severe and late sign of increased intracranial pressure and indicates significant neurological impairment. It is not typically seen as an early manifestation.
B) Restlessness: Restlessness is often one of the earliest signs of increased intracranial pressure. It can indicate changes in consciousness and may be the first observable change in a client's behavior as ICP begins to rise.
C) Projectile vomiting: This is usually a later sign of increased ICP and may occur as pressure continues to increase. It suggests significant involvement of the brain and is not an early manifestation.
D) Papilledema: While papilledema (swelling of the optic nerve head) can occur with increased ICP, it often takes time to develop and is not an immediate or early sign. It typically appears after sustained elevated ICP levels.
Correct Answer is C
Explanation
A) Respiratory rate 10/min: A respiratory rate of 10 breaths per minute indicates bradypnea, which may be concerning. However, this finding is not directly associated with metoprolol. Metoprolol primarily affects heart rate and blood pressure, making this less relevant in identifying an adverse effect of the medication.
B) Blood pressure 138/76 mm Hg: This blood pressure reading is within the normal range for most individuals. While metoprolol can lower blood pressure, this value does not indicate an adverse effect, as it shows adequate control rather than a concerning reaction.
C) Heart rate 48/min: A heart rate of 48 beats per minute indicates bradycardia, a known adverse effect of beta-blockers like metoprolol. In patients with heart failure, this can lead to insufficient cardiac output and may require intervention. Thus, this finding is critical and should be addressed immediately.
D) Temperature 36.3° C (97.3° F): This temperature is within the normal range and does not indicate an adverse effect related to metoprolol. While monitoring temperature is important, it is not a direct concern regarding the use of this medication.