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) "Use a raised toilet seat to maintain your hips above your knees.": This statement is appropriate because using a raised toilet seat helps prevent hip flexion beyond 90 degrees, which is crucial for clients recovering from a total hip arthroplasty. Maintaining proper positioning helps reduce the risk of dislocation and promotes safe mobility.
B) "Apply a heating pad to the operative hip to decrease pain.": While heat may provide comfort, it is generally advised to avoid applying heat directly to the surgical site, especially in the immediate postoperative period. Cold therapy is often recommended initially to reduce swelling and pain.
C) "Move your stronger leg first when using a walker.": This statement is incorrect for total hip arthroplasty patients. Typically, they should lead with the operated leg when using a walker to maintain proper alignment and safety during ambulation.
D) "Twist at the waist when standing from a seated position.": This instruction is inappropriate as twisting at the waist can increase the risk of dislocating the hip joint. Clients are generally advised to keep their body aligned and avoid twisting movements during the initial recovery period.
Correct Answer is B
Explanation
A) Cheyne-Stokes respirations: This pattern of breathing can indicate severe neurological impairment but typically arises after other signs of increased intracranial pressure (ICP) have emerged. It is more associated with significant brain dysfunction.
B) Altered level of consciousness: This is often the first sign of deteriorating neurological status in clients with increased ICP. Changes in consciousness can range from confusion and disorientation to lethargy or coma. Monitoring for these subtle shifts is crucial for early intervention.
C) Decorticate posturing: This is a sign of severe brain injury and indicates a significant level of impairment. However, it usually appears after alterations in consciousness and is not the initial sign.
D) Pupillary dilation: While changes in pupil size and reactivity are important indicators of neurological status, they often occur after a decline in consciousness. Altered consciousness typically precedes these changes.