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) Photophobia: This is a common symptom associated with meningitis. Inflammation of the meninges can lead to sensitivity to light, making photophobia a significant finding during the assessment of a client with meningitis. This symptom can cause discomfort and may lead clients to avoid bright environments.
B) Intermittent headache: While headaches are a common symptom of meningitis, they are typically severe and persistent rather than intermittent. Clients often report a continuous, severe headache that is different from their usual headaches, which is more indicative of meningitis.
C) Petechiae on the chest: Although petechiae can occur in certain types of meningitis, particularly meningococcal meningitis, it is not a universal finding. The presence of petechiae would suggest a more severe systemic involvement, but it is not expected in every case of meningitis.
D) Bradycardia: This is not a typical finding in meningitis. In fact, tachycardia (increased heart rate) is more commonly seen due to fever and infection. Bradycardia might indicate a different underlying issue and is not expected in the context of meningitis.
Correct Answer is C
Explanation
A) A client who has diabetes mellitus and is presenting with acute ketoacidosis: While this client requires careful monitoring and may need a private room if they are at risk for complications, they generally do not require isolation from other clients.
B) A client who has a compound fracture of the right femur: This client does not require a private room. Although they may need specific positioning and care, there are typically no infectious or isolation concerns.
C) A client who reports having fever, right sweats, and cough for 2 days: This client requires a private room due to the possibility of an infectious condition, such as pneumonia or tuberculosis. Symptoms like fever and cough, along with sweating, raise concerns about contagious diseases, making isolation necessary to protect other clients.
D) An older adult client who was admitted with aspiration pneumonia: While this client may need close monitoring, they do not automatically require a private room unless there are additional infection control concerns or if they are particularly contagious.