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)"Yourproviderwouldn'tprescribethismedicationifitweren'tnecessary.":Thisresponsereassurestheclientthatthemedicationisprescribedbasedonaprofessionalevaluationoftheirhealthneeds.Itemphasizestheimportanceofthemedicationwhilevalidatingtheprovider'sexpertiseanddecision-making.
B)"Iwilltellyourproviderthatyoudonotwanttotakethismedication.":Whileit'sessentialtocommunicatetheclient'sconcernstotheprovider,thisresponsemightsuggestthatthenurseisdismissingtheimportanceofthemedicationratherthanaddressingtheclient'sapprehensions.
C)"Ifyoudon'ttakethismedication,youwillfeelworse.":Thisstatementcancomeacrossasconfrontationalandmaynoteffectivelyaddresstheclient'sconcernsorhelpthemunderstandtheimportanceoftakingthemedication.
D)"Mostclientsfeelbetteraftertakingtheantibiotic.":Whilethisstatementmightbetrue,itissomewhatgenericanddoesn'tdirectlyaddresstheclient'sspecificconcernsortherationalebehindtheprescription.
Correct Answer is D
Explanation
A) "I will store prefilled syringes in the refrigerator with the needle pointed downward.": While prefilled syringes should be stored in the refrigerator, they should actually be stored with the needle pointing upward. This prevents the insulin from settling at the needle end and ensures that the insulin is readily available for injection. This statement reflects a misunderstanding of proper storage techniques.
B) "I will shake the NPH vial vigorously before drawing up the insulin.": NPH insulin should be gently rolled between the palms rather than shaken vigorously. Shaking can cause air bubbles and damage the insulin. This statement indicates a lack of understanding of the proper technique for preparing NPH insulin.
C) "I will insert the needle at a 15-degree angle.": The correct angle for injecting insulin is typically 90 degrees (or 45 degrees for thin clients), not 15 degrees. This statement shows a misunderstanding of proper injection technique.
D) "I will draw up the regular insulin into the syringe first.": This statement indicates an understanding of the proper technique for mixing insulins. When using both regular and NPH insulins, the regular insulin should always be drawn up first to prevent contamination of the short-acting insulin with the longer-acting insulin. This response reflects correct knowledge regarding insulin administration.