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?

Choice A rationale:

It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).

Early ambulation is generally encouraged to promote circulation and prevent blood clots.

Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.

Choice B rationale:

Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.

The patient's position should be based on their individual needs and comfort level.

In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.

Choice C rationale:

Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.

This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.

Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.

Choice D rationale:

Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.

This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.

If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.

Choice A rationale:

Paralytic ileus is a common postoperative complication that occurs when the normal movement of the intestines (peristalsis) is slowed or stopped. This can lead to a buildup of gas and fluids in the intestines, causing abdominal distention, nausea, vomiting, and constipation. The absence of bowel sounds, abdominal distention, and the inability to pass flatus are all classic signs of paralytic ileus.

Here are some of the factors that can contribute to paralytic ileus: Manipulation of the intestines during surgery

Anesthesia

Pain medications, especially opioids Electrolyte imbalances

Dehydration

Underlying medical conditions, such as diabetes or kidney disease Treatment for paralytic ileus typically involves:

Resting the bowel by not eating or drinking anything by mouth

Using a nasogastric (NG) tube to suction out gas and fluids from the stomach Providing intravenous (IV) fluids and electrolytes

Encouraging early ambulation

Using medications to stimulate bowel movement, such as metoclopramide or erythromycin

Choice B rationale:

Incisional infection is an infection of the surgical wound. It would typically present with redness, warmth, swelling, and pain at the incision site. The patient may also have a fever. While incisional infections can occur after abdominal surgery, they are not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.

Choice C rationale:

Fecal impaction is a severe form of constipation in which a large, hard mass of stool becomes trapped in the rectum. It can cause abdominal pain, bloating, and difficulty passing stool. However, it is not typically associated with the absence of bowel sounds or abdominal distention.

Choice D rationale:

Health care-associated Clostridium difficile (C. difficile) is a bacterial infection that can cause severe diarrhea, abdominal pain, and cramping. It is often associated with antibiotic use. While C. difficile can occur after abdominal surgery, it is not typically associated with the absence of bowel sounds, abdominal distention, and the inability to pass flatus.