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) Wear a surgical mask when providing care to the client.: This is the appropriate action because pertussis (whooping cough) is highly contagious and is transmitted via respiratory droplets. Wearing a surgical mask helps to protect the nurse and other staff from inhaling
these droplets when in close contact with the client.
B) Perform a Mantoux skin test on the client.: The Mantoux skin test is used for detecting tuberculosis exposure, not pertussis. Therefore, this action is not relevant for a client with pertussis and does not address the immediate needs of the situation.
C) Assign the client to a negative-pressure airflow room.: Negative-pressure rooms are typically used for airborne precautions, such as for tuberculosis or COVID-19. Pertussis requires droplet precautions, not airborne precautions, making this option unnecessary.
D) Recommend that the client's family members receive antiviral therapy.: While family members may need prophylactic antibiotics, antiviral therapy is not indicated for pertussis. Instead, they should receive antibiotics like azithromycin or erythromycin to prevent the spread of the disease.
Correct Answer is B
Explanation
A) Increased urine output: This finding is more commonly associated with hyperglycemia and diabetic ketoacidosis, where the body attempts to excrete excess glucose through urine. In hypoglycemia, urine output is typically not increased.
B) Cold, clammy skin: This is a classic symptom of hypoglycemia. As blood sugar levels drop, the body releases adrenaline, which can cause sweating and result in cold, clammy skin. This finding directly supports the suspicion of hypoglycemia.
C) Acetone breath: This is associated with diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. The presence of acetone on the breath indicates the breakdown of fat for energy, not a low blood sugar state.
D) Kussmaul respirations: These deep, labored breaths are typically seen in metabolic acidosis, particularly in diabetic ketoacidosis. They are not indicative of hypoglycemia.