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 {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.
The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.
After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.
The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.
Correct Answer is B
Explanation
Choice A rationale
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.