A nurse is caring for a patient who is postoperative following abdominal surgery.
The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do?
Gently reinsert the bowel back into the patient’s wound.
Place the head of the patient’s bed in the flat position.
Apply moistened sterile gauze to the site.
Position the patient on his left side.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acute laryngotracheobronchitis, also known as croup, is a common childhood condition that is usually caused by a viral infection. The main symptom is a distinctive barking cough. A cool mist tent can help to soothe the inflamed airways and reduce stridor, which is a high-pitched,
wheezing sound caused by disrupted airflow. Therefore, decreased stridor would indicate that the treatment has been effective.
Choice B rationale
While a decreased temperature might indicate a resolution of any underlying infection, it is not directly related to the effectiveness of a cool mist tent in treating acute laryngotracheobronchitis.
Choice C rationale
A barking cough is a symptom of acute laryngotracheobronchitis and does not indicate treatment effectiveness.
Choice D rationale
Improved hydration is important but is not a direct indicator of the effectiveness of the cool mist tent.
Correct Answer is C
Explanation
Choice A rationale
Streptococcal pharyngitis, also known as strep throat, is a bacterial infection that causes inflammation and pain in the throat. This condition is spread through respiratory droplets, not through the air, and does not require airborne precautions.
Choice B rationale
Scabies is caused by a mite infestation, not an airborne pathogen. It is spread through direct skin-to-skin contact and does not require airborne precautions.
Choice C rationale
Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing, and the measles virus can live for up to two hours in an airspace where the infected person coughed or sneezed. Therefore, a patient with measles requires airborne precautions.
Choice D rationale
Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. It spreads through close contact with respiratory droplets when an infected person coughs or sneezes. It is typically managed with droplet precautions, not airborne precautions.
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