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) Check settings of the CPM machine every 12 hr: This is not frequent enough. The nurse should check the settings of the CPM machine more regularly, typically before each use or every few hours, to ensure the settings are appropriate for the client's therapy.
B) Increase the range of motion rapidly when the CPM machine is used intermittently: This approach is not safe. The range of motion should be increased gradually based on the healthcare provider's orders and the client's tolerance to avoid injury or discomfort.
C) Store the CPM machine on the floor when not in use: Storing the CPM machine on the floor can pose safety hazards, such as tripping or damage to the machine. It should be stored in a safe, designated area when not in use.
D) Turn the CPM machine off while the client is eating: This is an appropriate action. It allows the client to eat comfortably and without obstruction, ensuring they can focus on eating without the machine interfering. Once the client has finished eating, the CPM machine can be turned back on to continue therapy.
Correct Answer is B
Explanation
A) Cheyne-Stokes respirations: This pattern of breathing can indicate severe neurological impairment but typically arises after other signs of increased intracranial pressure (ICP) have emerged. It is more associated with significant brain dysfunction.
B) Altered level of consciousness: This is often the first sign of deteriorating neurological status in clients with increased ICP. Changes in consciousness can range from confusion and disorientation to lethargy or coma. Monitoring for these subtle shifts is crucial for early intervention.
C) Decorticate posturing: This is a sign of severe brain injury and indicates a significant level of impairment. However, it usually appears after alterations in consciousness and is not the initial sign.
D) Pupillary dilation: While changes in pupil size and reactivity are important indicators of neurological status, they often occur after a decline in consciousness. Altered consciousness typically precedes these changes.