A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect?

Choice A rationale

Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This “telescoping” often blocks food or fluid from passing through.

Intussusception also cuts off the blood supply to the part of the intestine that’s affected. It can lead to a tear in the bowel (perforation), infection and death of bowel tissue.

Choice B rationale

Wilms’ tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms’ tumor is the most common cancer of the kidneys in children. Wilms’ tumor most often affects children ages 3 to 4 and becomes much less common after age 52.

Choice C rationale

Pyloric stenosis is a condition that affects infants between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It’s the second most common reason why newborns have surgery. Pyloric stenosis can be fixed with a surgical procedure called pyloromyotomy.

Choice D rationale

Nephrotic syndrome is a kidney disorder that causes your body to excrete too much protein in your urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your kidneys that filter waste and excess water from your blood.

Choice A rationale

Gently reinserting the bowel back into the patient’s wound is not recommended. This could cause further harm to the patient.

Choice B rationale

Placing the head of the patient’s bed in the flat position is not the best action. This position may not provide the necessary comfort or safety for the patient.

Choice C rationale

Applying moistened sterile gauze to the site is the correct action. This helps to protect the protruding bowel and prevent further contamination until surgical intervention can be performed.

Choice D rationale

Positioning the patient on his left side is not the best action in this situation. It does not directly address the issue of the protruding bowel.