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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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.
Correct Answer is C
Explanation
A) Lidocaine: Lidocaine is primarily used for the management of ventricular arrhythmias, particularly in cases of ventricular tachycardia or ventricular fibrillation. It is not indicated for treating sinus bradycardia and ST segment elevation.
B) Digoxin: Digoxin is used to treat atrial fibrillation and heart failure but is not appropriate for acute management of sinus bradycardia. In fact, digoxin can potentially worsen bradycardia by increasing vagal tone.
C) Atropine: Atropine is the drug of choice for acute management of symptomatic bradycardia. It works by blocking the effects of the vagus nerve on the heart, which can increase heart rate. Given the client's symptoms of shortness of breath and dizziness, atropine is appropriate to help stabilize their condition.
D) Sotalol: Sotalol is an antiarrhythmic medication used primarily for atrial fibrillation and ventricular arrhythmias. It is not indicated for the treatment of bradycardia and may even exacerbate the condition.