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) Check the pulse distal to the graft: This action is crucial for assessing the patency of the arteriovenous graft. Monitoring the pulse distal to the graft ensures adequate blood flow and helps detect any complications such as thrombosis or compromised circulation.
B) Keep the left forearm below the level of the heart: Keeping the forearm below heart level is not necessary and could potentially compromise circulation. The limb should be elevated as tolerated to reduce swelling and promote healing.
C) Collect blood specimens from the graft: Collecting blood specimens from the graft site is not appropriate, as it can increase the risk of infection and damage to the graft. Blood samples should typically be drawn from another site.
D) Splint the left forearm to prevent damage to the graft: While protecting the graft site is important, splinting is generally not required unless specifically ordered for a particular reason. The focus should be on gentle use and monitoring rather than immobilization.
Correct Answer is C
Explanation
A) Monitor the client's vital signs once every hour: After a cardiac catheterization, it is crucial to monitor vital signs more frequently than every hour. The nurse should assess vital signs every 15 minutes for the first hour, then every 30 minutes for the next two hours, and
then according to the facility's protocol, to quickly identify any complications.
B) Elevate the head of the client's bed to a 45° angle: Elevating the head of the bed to a 45° angle is generally not recommended immediately following cardiac catheterization through the femoral artery. The client should remain flat or with the head elevated no more than 30 degrees to reduce the risk of bleeding from the access site.
C) Instruct the client not to bend the affected leg: This is the most appropriate action. Keeping the affected leg straight is essential to prevent complications such as bleeding or hematoma formation at the catheter insertion site. The client should be instructed to avoid bending or flexing the leg for a specified period, usually several hours post-procedure.
D) Restrict the client's fluid intake: Restricting fluid intake is not necessary after cardiac catheterization. In fact, adequate hydration is often encouraged to help flush the contrast dye from the system and maintain kidney function, provided there are no contraindications.