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 D
Explanation
A) Avoid administering IV pain medication: While caution is warranted when administering IV medications to a client with petechiae, particularly if thrombocytopenia is suspected, avoiding pain management is not the appropriate action. Pain relief is crucial for the client’s comfort, and IV medications can be safely administered with proper precautions.
B) Determine the client's blood type: Knowing the client's blood type is important for transfusion purposes, especially if there is significant bleeding. However, this action is not the immediate priority in response to the observation of petechiae. The presence of petechiae is more directly related to bleeding risk rather than blood type.
C) Implement airborne precautions: Airborne precautions are necessary for certain infections (e.g., tuberculosis), but they are not indicated for the management of petechiae related to chronic lymphocytic leukemia. The presence of petechiae does not suggest an airborne infection; thus, this action does not address the immediate concern.
D) Institute bleeding precautions: Petechiae indicate a potential for bleeding due to thrombocytopenia, which is common in clients with chronic lymphocytic leukemia. Instituting bleeding precautions, such as using a soft toothbrush, avoiding invasive procedures, and monitoring for additional signs of bleeding, is crucial to prevent serious complications. Therefore, this action is the most appropriate and immediate response.
Correct Answer is D
Explanation
A) 10: A score of 10 on the Glasgow Coma Scale (GCS) indicates a moderate level of impairment in consciousness. This score typically includes a range of responses in eye opening, verbal, and motor responses. Given the client's specific symptoms, this score does not accurately reflect their condition.
B) 13: A GCS score of 13 indicates mild impairment. This score usually requires the ability to open eyes spontaneously, follow commands, and exhibit appropriate verbal responses. Since the client is not opening their eyes and only making incomprehensible sounds, this score is not applicable.
C) 2: A score of 2 on the GCS would imply a severely compromised response, but it would be misleading since the client exhibits decerebrate posturing, which is a significant motor response indicating a level of neurological function. Thus, this score does not adequately represent the client's status.
D) 5: This is the correct score. The GCS includes a score of 1 for no eye opening, 2 for incomprehensible sounds, and 2 for decerebrate posturing. Adding these together (1 for eye opening + 2 for verbal + 2 for motor) results in a total of 5. This score reflects the severe impairment of consciousness and indicates the need for urgent medical evaluation and intervention.