A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

Check the client’s vital signs.

Inform the client about the need to return to surgery.

Have the client lie supine with knees flexed.

Cover the client’s wound with a moist, sterile dressing.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

Choice A rationale:

Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.

The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).

Choice B rationale:

Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.

The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.

Choice C rationale:

Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.

The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).

Choice D rationale:

Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.

The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).

A. Recap needles and place them in a wastebasket. B. Do not recap the needle on an ABG specimen. C. Place uncapped needles in a puncture-proof container after use. D. Break needles in half before putting them in the sharps disposal box.

Correct Answer is C

Explanation

Choice A rationale:

Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.

The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.

Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.

Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.

Choice B rationale:

While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.

Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.

Choice D rationale:

Breaking needles in half is not recommended as a standard practice for needle disposal.

This action can create sharp fragments that are difficult to handle and can still cause injuries.

Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.

Choice C rationale:

Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.

These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.

Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.

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A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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