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) Internal fixation of a fractured hip. This procedure is associated with a higher risk of fat embolism syndrome (FES) due to the release of fat globules from the bone marrow into the bloodstream following trauma or surgery to long bones. The likelihood increases after orthopedic surgeries, especially in the hip and pelvis regions, where bone marrow is rich. Recognizing this risk is critical for monitoring and early intervention.
B) Repair of a torn rotator cuff. While this procedure involves surgery on the shoulder, it is not typically associated with a significant risk of fat embolism. The shoulder region does not contain the same volume of fatty tissue or bone marrow as the hip, making this option less likely to contribute to FES.
C) Thyroidectomy. This procedure is primarily focused on the thyroid gland in the neck and does not involve manipulation of large bones or fatty tissues, thus posing a minimal risk for fat embolism syndrome. It is more related to complications like hypoparathyroidism or nerve injury rather than fat embolism.
D) Tympanoplasty. This ear surgery involves repairing the eardrum and does not present a risk for fat embolism. The procedure is localized and does not involve significant manipulation of fatty tissues or large bones, making it unlikely to contribute to FES.
Correct Answer is D
Explanation
A)"Ishouldusenaturalskincondomsduringsexualintercourse.":Naturalskincondomsdonotprotectagainstviralinfectionslikeherpes.Latexorpolyurethanecondomsshouldbeusedtohelpreducetheriskoftransmittinggenitalherpes.
B)"Ishouldapplyantibioticointmenttothelesions.":Antibioticointmentsarenoteffectiveagainstviralinfectionslikeherpes.Antiviralmedicationsarenecessarytotreatandmanageherpeslesions.
C)"Ishouldexpectmylesionstoresolvein6weeks.":Lesionsfromgenitalherpestypicallyresolvewithinafewweeks,notsix.Aprolongeddurationmightindicatecomplicationsortheneedforadditionalmedicalevaluation.
D)"Ishouldexpecttotakemymedicationfor3weeks.":Antiviralmedicationsareoftenprescribedforaspecificduration,suchasthreeweeks,tohelpmanagetheoutbreakandreducesymptoms.Thisindicatestheclientunderstandsthetreatmentregimen.