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) Chloride level: Chloride levels are generally not affected by gout. While electrolyte imbalances can occur in various conditions, they are not specifically associated with acute gout attacks.
B) Uric acid: An increase in uric acid levels is expected in clients with acute gout. Gout is caused by the accumulation of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels is crucial for diagnosing and managing this condition.
C) Creatinine kinase: Creatinine kinase levels are typically elevated in conditions related to muscle damage or injury, rather than gout. While some muscle soreness may occur during a gout flare, it is not a primary indicator for this condition.
D) Intrinsic factor: Intrinsic factor is related to vitamin B12 absorption and is not relevant to gout. It is primarily associated with conditions like pernicious anemia rather than gout or uric acid metabolism.
Correct Answer is C
Explanation
Diphenhydramine: This is an antihistamine primarily used to treat allergies and as a sedative. It is not indicated for reversing opioid-induced respiratory depression and could potentially worsen the sedation.
Flumazenil: This medication is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines. It is not effective for opioid overdose or respiratory depression caused by morphine.
Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. In cases of opioid-induced respiratory depression, naloxone is the appropriate medication to administer to restore normal respiratory function.
Calcium gluconate: This medication is used for conditions such as hypocalcemia or magnesium toxicity, but it is not relevant for opioid overdose or respiratory depression.