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) The client moves the cane 2 feet ahead.: Moving the cane 2 feet ahead is not appropriate, as the cane should be positioned close to the body to provide support. The cane is typically moved just ahead of the weaker leg to help with balance and support.
B) The client takes a step with their right foot first.: This action does not align with the recommended method for using a quad cane with left-sided weakness. The correct technique involves moving the cane and the weaker leg together, which helps maintain balance.
C) The client holds the cane with their left hand.: This action demonstrates an understanding of how to use a quad cane effectively. Holding the cane with the stronger hand (the right hand in this case) is generally recommended, but if the client has left-sided weakness and needs to use the cane for stability, they would typically hold it with their left hand to maintain balance while stepping with the right leg.
D) The client advances the weaker leg forward to the cane.: This action indicates a misunderstanding. The correct method involves advancing the cane first, followed by the weaker leg, to ensure proper support and balance.
Correct Answer is A
Explanation
A) Discard samples that contain urine: This is the correct action. Urine can contaminate the fecal sample and lead to false-positive results. Ensuring that the sample is free from urine is essential for accurate testing.
B) Take the sample from the outer edge of formed stool: While it is important to collect from a clean area, the preferred method is to take samples from different areas of the stool, not just the outer edge, to ensure representative testing.
C) Wear sterile gloves when collecting the sample: While wearing gloves is important for infection control, non-sterile gloves are typically sufficient for this type of procedure. The focus should be on avoiding contamination of the sample rather than sterility.
D) Collect three samples from a single bowel movement: This statement is incorrect; the standard practice is to collect samples from three different bowel movements on different days, rather than multiple samples from a single event, to increase the reliability of the test results.