The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]
Cover the bowel with wet sterile gauze
Assist the client into a low-Fowler's position with knees flexed
Assist the client into a side-lying position with knees flexed
Retrieve the crash cart from the nursing station
Call for assistance
Measure the client's inspiratory volume via incentive spirometer
Correct Answer : A,B,E
A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.
B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.
C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.
D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.
E: Calling for assistance is essential to notify the surgical or medical team promptly.
F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. PCA pumps allow clients to self-administer pain medication within prescribed limits when experiencing pain.
B. Doses are controlled by a lockout mechanism to prevent overdosing.
C. PCA pumps deliver medication as needed, not a continuous infusion unless programmed otherwise.
D. The client independently determines when to use the PCA within prescribed parameters.
Correct Answer is A
Explanation
A. Herbs and supplements can interact with anesthesia or affect coagulation, increasing perioperative risks.
B. Lactose intolerance is unlikely to impact surgery unless dietary considerations postoperatively involve lactose-containing foods.
C. A lack of prior surgical experience is relevant but not critical compared to medication or supplement interactions.
D. Bee/wasp allergies are important but less urgent unless directly related to medications or procedures used.
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