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) Slow infusion rate and contact the provider: The client is exhibiting signs of fluid overload, as evidenced by dyspnea and a relatively high blood pressure, along with a significant positive fluid balance (960 mL intake versus 300 mL output). Slowing the infusion rate allows for better management of fluid status, while contacting the provider is crucial to reassess the treatment plan and address potential complications.
B) Change infusion to lactated Ringer's and maintain rate: This action is inappropriate because the underlying issue appears to be fluid overload rather than the type of fluid being administered. Changing the infusion to a different type of fluid does not address the need to manage the current fluid overload situation.
C) Administer prescribed corticosteroids: While corticosteroids may be indicated for certain conditions, in this scenario, the priority is addressing the client's immediate signs of fluid overload rather than administering corticosteroids without further assessment.
D) Lower the head of the bed to semi-Fowler's: While positioning the client to promote comfort and ease breathing is important, the more critical intervention is to address the infusion rate and contact the provider regarding the client’s deteriorating condition. Lowering the head of the bed does not address the underlying problem of fluid overload.
Correct Answer is A
Explanation
A) Assess urine output hourly. Monitoring urine output hourly is critical in the postoperative care of a client following a kidney transplant. It helps assess kidney function and detect any potential complications such as acute rejection or acute tubular necrosis early. Changes in urine output can provide important information about the client's fluid status and renal perfusion.
B) Check the client's blood pressure every 8 hr. While monitoring blood pressure is important, it is not sufficient to check it only every 8 hours in the immediate postoperative period. Blood pressure can fluctuate significantly due to factors such as fluid status, medication effects, and potential complications. More frequent monitoring, especially in the first 24 hours, is essential for timely intervention.
C) Monitor for hypokalemia as a manifestation of acute rejection. Hypokalemia is not typically a manifestation of acute rejection following a kidney transplant; rather, hyperkalemia is more commonly observed due to impaired kidney function. Therefore, focusing on monitoring for signs of hyperkalemia would be more relevant in this context.
D) Administer opioids PO. While pain management is crucial after surgery, opioids are often administered intravenously in the immediate postoperative period for better control and quicker action. Oral administration may be appropriate later when the client is stable and can tolerate oral medications.