A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.
What type of drainage should the nurse report?

The correct answer is Choice D: Cover the client's wound with a moist, sterile dressing.

Choice D rationale: In the case of a client with a bowel protrusion from an abdominal incision, the immediate priority is to protect the exposed bowel and minimize the risk of further damage or infection. Covering the wound with a moist, sterile dressing serves to maintain tissue viability, prevent dehydration, and provide a protective barrier against contamination. This intervention preserves the integrity of the exposed bowel while awaiting further medical or surgical management.

Choice A rationale: Checking the client's vital signs is an essential aspect of postoperative care and may be indicative of the client's overall status, but it is not the first action in the case of bowel evisceration. Immediate attention should be directed towards protecting the exposed bowel, with vital signs being monitored closely thereafter to ensure the client's stability.

Choice B rationale: Informing the client about the need for a return to surgery is an important step in the client's care, as it allows for informed consent and understanding of the situation. However, in this scenario, the priority is to address the immediate issue of bowel exposure and provide initial care to the compromised tissue. Once the exposed bowel is appropriately managed, the client should be informed about the potential need for further surgical intervention.

Choice C rationale: Positioning the client in a supine position with knees flexed may help reduce abdominal tension and minimize further protrusion, but it is not the immediate action to take when faced with bowel evisceration. The initial focus should be on protecting the exposed bowel through the application of a moist, sterile dressing, followed by measures to optimize the client's position and promote tissue integrity.

Choice A rationale:

Notifying the facility's security department may be necessary in some cases, but it should not be the nurse's first action. This could escalate the situation and make the patient feel threatened or coerced. It's important to first attempt to de-escalate the situation and understand the patient's reasons for wanting to leave. Involving security prematurely could damage the nurse- patient relationship and make it more difficult to provide care in the future.

Security should be involved if the patient is a danger to themselves or others, or if they are attempting to leave in a way that could cause harm. However, in most cases, it is best to try to resolve the situation through communication and understanding.

Choice B rationale:

Calling the patient's family may be helpful in some cases, but it is not always necessary or appropriate. The nurse should first assess the patient's decision-making capacity and their understanding of the risks of leaving against medical advice. If the patient is capable of making their own decisions, the nurse should respect their autonomy and not involve family members without their consent.

Involving family members without the patient's consent could breach confidentiality and erode trust. It's important to balance the patient's right to privacy with the potential benefits of involving family members.

Choice C rationale:

Insisting that the patient exit the hospital via a wheelchair is not necessary in most cases. If the patient is able to walk and does not pose a safety risk, they should be allowed to leave on their own terms. Requiring a wheelchair could be seen as patronizing or controlling, and it could further upset the patient.

The use of a wheelchair should be based on the patient's individual needs and preferences, not on a blanket policy.

Choice D rationale:

Making sure the patient understands that they are leaving against medical advice is the most important action the nurse can take. This ensures that the patient is aware of the potential risks of leaving the hospital, and it protects the nurse from liability. The nurse should document the patient's decision in the medical record and have the patient sign an Against Medical Advice (AMA) form.

By ensuring informed consent, the nurse respects the patient's autonomy while also fulfilling their professional obligations.