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) Obtain the client's vital signs: While obtaining vital signs is important after a seizure, it is not the immediate priority during the seizure event. The focus should be on ensuring the client's safety.
B) Lower the client to the floor: Lowering the client to the floor can be a helpful action if the client is standing, but it is not the first step. If the client is already on the floor, this action may not be necessary.
C) Clear items from the client's surrounding area: This is the first action the nurse should take. Clearing the area helps prevent injury to the client during the seizure, ensuring that no objects could potentially cause harm. Safety is the immediate priority during a seizure.
D) Loosen the client's restrictive clothing: While loosening restrictive clothing can be beneficial, it is a secondary action. The primary concern during a seizure is to ensure the client's immediate safety by clearing the surrounding area.
Correct Answer is A
Explanation
A) Slow infusion rate and contact the provider: The client is exhibiting signs of fluid overload, as evidenced by dyspnea and a relatively high blood pressure, along with a significant positive fluid balance (960 mL intake versus 300 mL output). Slowing the infusion rate allows for better management of fluid status, while contacting the provider is crucial to reassess the treatment plan and address potential complications.
B) Change infusion to lactated Ringer's and maintain rate: This action is inappropriate because the underlying issue appears to be fluid overload rather than the type of fluid being administered. Changing the infusion to a different type of fluid does not address the need to manage the current fluid overload situation.
C) Administer prescribed corticosteroids: While corticosteroids may be indicated for certain conditions, in this scenario, the priority is addressing the client's immediate signs of fluid overload rather than administering corticosteroids without further assessment.
D) Lower the head of the bed to semi-Fowler's: While positioning the client to promote comfort and ease breathing is important, the more critical intervention is to address the infusion rate and contact the provider regarding the client’s deteriorating condition. Lowering the head of the bed does not address the underlying problem of fluid overload.