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.

Answer and Explanation

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.

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Correct Answer is ["A","D"]

Explanation

Choice A rationale

In ARDS, impaired carbon dioxide elimination due to shunting can occur. Shunting refers to the diversion of blood from areas of the lung that are ventilated to areas that are not, leading to impaired gas exchange.

Choice B rationale

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is not a typical finding in ARDS3.

Choice C rationale

Hypoxemia due to dead space is not a typical finding in ARDS. Dead space refers to areas of the lung that are ventilated but not perfused.

Choice D rationale

Decreased pulmonary compliance due to stiffness is a typical finding in ARDS. The lungs become stiff and less compliant due to the accumulation of fluid and inflammatory cells in the alveoli and interstitial space.

A. Measure the patient’s apical pulse. B. Offer the patient a light snack. C. Check the patient’s blood pressure. D. Weigh the patient.

Correct Answer is A

Explanation

Choice A rationale

Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.

Choice B rationale

Offering a light snack is not specifically required before administering digoxin.

Choice C rationale

While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.

Choice D rationale

Weighing the patient is not specifically required before administering digoxin.

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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?

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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?