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 B
Explanation
A) Decorticate posturing: This is a more severe and late sign of increased intracranial pressure and indicates significant neurological impairment. It is not typically seen as an early manifestation.
B) Restlessness: Restlessness is often one of the earliest signs of increased intracranial pressure. It can indicate changes in consciousness and may be the first observable change in a client's behavior as ICP begins to rise.
C) Projectile vomiting: This is usually a later sign of increased ICP and may occur as pressure continues to increase. It suggests significant involvement of the brain and is not an early manifestation.
D) Papilledema: While papilledema (swelling of the optic nerve head) can occur with increased ICP, it often takes time to develop and is not an immediate or early sign. It typically appears after sustained elevated ICP levels.
Correct Answer is B
Explanation
A) Fever: While fever can occur in various allergic reactions, it is not a specific indicator of anaphylaxis. It may signal an infection or other inflammatory process rather than an immediate hypersensitivity reaction.
B) Laryngeal edema: This is a hallmark sign of anaphylaxis. It indicates swelling in the throat that can compromise the airway, making it a critical and life-threatening response. Immediate recognition and intervention are necessary to ensure the client's airway remains patent.
C) Hypertension: Although anaphylaxis can sometimes lead to hypotension due to vascular collapse, hypertension is not typically a sign of anaphylaxis. Instead, hypotension is more commonly associated with severe allergic reactions.
D) Arrhythmia: While arrhythmias can occur due to various causes, including stress or electrolyte imbalances, they are not a direct indicator of anaphylaxis. Anaphylaxis primarily presents with respiratory symptoms, skin reactions, and gastrointestinal symptoms, rather than primarily affecting heart rhythm.