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) Gently elevate the client's head and note any nuchal rigidity: This action is crucial for assessing for meningeal irritation, which is a common sign of bacterial meningitis. Nuchal rigidity refers to stiffness in the neck that makes it difficult for the client to flex their neck forward. This sign, along with other symptoms, can help confirm the suspicion of meningitis.

B) Strike the client's patellar tendon with a percussion hammer and note any increase in response: While assessing deep tendon reflexes can provide information about neurological function, it is not specific to meningitis. Increased reflex response may not
directly indicate meningeal irritation.

C) Tap the client's facial nerve and note any facial twitching: This action is not a standard assessment for bacterial meningitis. Facial twitching could indicate other neurological issues but is not specifically related to meningitis.

D) Run a tongue blade on the outside of the client's sole and note any flaring of the toes: This action describes the Babinski reflex, which is not a typical assessment for meningitis. It may indicate upper motor neuron lesions but does not specifically assess for meningitis.

A. Remind the client of the importance of medication adherence. B. Tell the client to avoid places where there are large crowds of people. C. Initiate a referral for the client to a home health agency. D. Instruct the client to avoid eating raw vegetables.

Correct Answer is C

Explanation

A) Remind the client of the importance of medication adherence.: While emphasizing medication adherence is important, it does not directly advocate for the client's needs related to self-care at home. It is more of a standard teaching point rather than a specific action to support the client's independence.

B) Tell the client to avoid places where there are large crowds of people.: Advising the client to avoid crowded places is a precaution to prevent infection, but it does not empower the client or help them maintain their self-care abilities. Advocacy involves supporting the client's choices and helping them navigate their circumstances.
C) Initiate a referral for the client to a home health agency.: This action demonstrates client advocacy by actively seeking resources that can provide the client with the support they need to manage their care at home. A home health agency can offer assistance with medication management, monitoring health status, and providing companionship, which aligns with the client's goal of self-care while living alone.

D) Instruct the client to avoid eating raw vegetables.: While this is a valid dietary recommendation for someone with a compromised immune system, it does not specifically advocate for the client’s self-care or independence. It is a preventive measure rather than a supportive action that empowers the client.

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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

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