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.

Answer and Explanation

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) Internal fixation of a fractured hip. This procedure is associated with a higher risk of fat embolism syndrome (FES) due to the release of fat globules from the bone marrow into the bloodstream following trauma or surgery to long bones. The likelihood increases after orthopedic surgeries, especially in the hip and pelvis regions, where bone marrow is rich. Recognizing this risk is critical for monitoring and early intervention.

B) Repair of a torn rotator cuff. While this procedure involves surgery on the shoulder, it is not typically associated with a significant risk of fat embolism. The shoulder region does not contain the same volume of fatty tissue or bone marrow as the hip, making this option less likely to contribute to FES.

C) Thyroidectomy. This procedure is primarily focused on the thyroid gland in the neck and does not involve manipulation of large bones or fatty tissues, thus posing a minimal risk for fat embolism syndrome. It is more related to complications like hypoparathyroidism or nerve injury rather than fat embolism.

D) Tympanoplasty. This ear surgery involves repairing the eardrum and does not present a risk for fat embolism. The procedure is localized and does not involve significant manipulation of fatty tissues or large bones, making it unlikely to contribute to FES.

A. Acute loss of alveolar elasticity B. Decreased responsiveness of airways to allergens C. Suppressed bronchiolar inflammatory response D. Inability to exhale retained carbon dioxide

Correct Answer is D

Explanation

A) Acute loss of alveolar elasticity: While loss of alveolar elasticity can impact overall lung function, it is more associated with chronic conditions like emphysema rather than acute asthma attacks. In asthma, the primary issue is related to airway obstruction and inflammation rather than alveolar elasticity.

B) Decreased responsiveness of airways to allergens: During an acute asthma attack, the airways typically exhibit increased sensitivity and responsiveness to allergens and irritants, not decreased responsiveness. This heightened response contributes to the bronchoconstriction and inflammation seen in asthma.

C) Suppressed bronchiolar inflammatory response: In an asthma attack, there is actually an exaggerated inflammatory response in the bronchioles. This inflammation leads to swelling, mucus production, and bronchoconstriction, which contribute to the difficulty in breathing.

D) Inability to exhale retained carbon dioxide: This is a significant factor during an acute asthma attack. The bronchoconstriction and airway obstruction make it difficult for the client to exhale fully, leading to the retention of carbon dioxide. This can cause respiratory acidosis and worsen the client's condition, highlighting the urgency of treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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