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 C
Explanation
A) Generalized abdominal pain: While abdominal pain can occur with peritonitis, it is not always the earliest indication. Pain may develop after other symptoms become apparent, making it less specific as an initial sign.
B) Fever: Fever is a common symptom of infection, including peritonitis. However, it can also occur in various other conditions and may not be the first noticeable symptom, especially if the infection is localized.
C) Cloudy effluent: Cloudy or turbid dialysate effluent is often the earliest and most specific indication of peritonitis in patients undergoing peritoneal dialysis. This change in the appearance of the effluent suggests an infection, and the presence of cloudy fluid should prompt further evaluation for peritonitis.
D) Increased heart rate: An increased heart rate can be a response to various conditions, including infection, but it is not specific to peritonitis and may not be the earliest sign.
Correct Answer is ["A","B","C","D"]
Explanation
A) Place the client in an upright sitting position: This is the first step because it helps to lower blood pressure by promoting venous return and decreasing the effects of increased sympathetic activity associated with autonomic dysreflexia. Immediate positioning can alleviate acute symptoms and prevent further complications.
B) Confirm that the client's bladder is empty: After ensuring the client is positioned appropriately, the next step is to check for urinary retention, which is a common trigger for autonomic dysreflexia. If the bladder is full, it can exacerbate the condition, so emptying it is crucial.
C)Indicate the risk for autonomic dysreflexia in the client's medical record: While this step is important for ongoing patient care and documentation, it is not an immediate priority during an acute episode of autonomic dysreflexia. Documenting the risk should occur after addressing the client's immediate needs to ensure their safety and well-being
D)Administer an antihypertensive medication intravenously: If the client's blood pressure remains elevated after positioning and emptying the bladder, the next step is to provide pharmacological intervention. Administering an antihypertensive medication can help manage and stabilize the client's blood pressure effectively.