A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?
Prepare the client for surgery.
Cover the protrusion with a dressing soaked in 0.9% sodium chloride.
Obtain the client's vital signs every 5 min until the provider arrives.
Raise the head of the bed to 20°.
The Correct Answer is B
A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.
B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.
C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.
D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. PO oxycodone: Oral medications are contraindicated in clients with paralytic ileus because of impaired gastrointestinal motility, which prevents proper absorption and increases the risk of gastric retention. IV administration is preferred for effective pain control in this scenario.
B. Ibuprofen via NG tube: NSAIDs can cause gastric irritation and increase the risk of gastrointestinal bleeding, especially in clients with pancreatitis. Additionally, an NG tube is not an appropriate route for medication administration in the presence of an ileus due to impaired intestinal function.
C. IV hydromorphone: IV opioids provide effective and rapid pain relief for clients with severe pain, especially when oral or enteral administration is not feasible. Hydromorphone is commonly used in acute pancreatitis because it controls pain effectively without exacerbating the underlying condition.
D. Topical lidocaine patch: While lidocaine patches provide localized pain relief, they are not sufficient for managing severe visceral pain associated with pancreatitis and ileus. Systemic analgesia via IV opioids is more appropriate for controlling this level of pain.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B,C"}}
Explanation
Sickle Cell Disease:
• Fatigue
Iron Deficiency Anemia:
• Ferritin level
• Fatigue
• Orthostatic hypotension
Pernicious Anemia:
• Vitamin B12 level
• Fatigue
Rationale:
• Vitamin B12 level: A decreased vitamin B12 level is characteristic of pernicious anemia, which results from impaired absorption of vitamin B12 due to intrinsic factor deficiency.
• Orthostatic hypotension: A drop in blood pressure upon standing is commonly seen in iron deficiency anemia due to reduced oxygen-carrying capacity and inadequate perfusion.
• Ferritin level: A low ferritin level indicates depleted iron stores, which is a hallmark of iron deficiency anemia.
• Fatigue: Fatigue is a common symptom in all three conditions due to reduced oxygen delivery to tissues. In sickle cell disease, fatigue results from chronic hemolysis and vaso-occlusive episodes. In iron deficiency anemia, it is caused by insufficient hemoglobin production. In pernicious anemia, fatigue results from ineffective erythropoiesis due to vitamin B12 deficiency.
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