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 C
Explanation
A) Blistering at the site: Blistering is typically associated with partial-thickness burns rather than full-thickness burns. Full-thickness burns destroy both the epidermis and dermis, which usually do not present with blisters.
B) Epithelialization at the site: Epithelialization is a healing process that occurs after the burn site begins to heal. Since this client has sustained major full-thickness burns only 12 hours ago, epithelialization is not expected at this early stage.
C) Edema at the site: Edema is expected in the early stages following a major burn injury due to the inflammatory response and fluid shift that occurs. This finding aligns with the body's response to trauma and is common within the first 24 hours after a burn.
D) Severe pain at the site: Full-thickness burns typically have less pain at the site compared to partial-thickness burns because the nerve endings in the skin are destroyed. While there may be pain in surrounding areas or in partial-thickness areas, the full-thickness burn itself is often painless.
Correct Answer is D
Explanation
A) A client who has a headache following a grade 1 concussion: While this client may need monitoring, they are likely stable and do not require constant observation. Therefore, their placement can be further from the nurses' station.
B) A client who has experienced brain death and is awaiting organ procurement: This client may require occasional monitoring, but their condition is stable and less critical in terms of immediate nursing observation compared to those with fluctuating neurological statuses.
C) A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack: A score of 0 indicates no neurological deficits at the time of assessment. This client is stable and does not necessarily require close observation.
D) A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash: A score of 10 indicates altered consciousness and potential risk for deterioration. This client requires closer monitoring and immediate access to nursing care, making it appropriate to assign them to a room closest to the nurses' station.