The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Cover the bowel with a sterile saline dressing.

Raise the patient up to a high Fowler's position.

Call the RN.

Turn the patient to the side of the evisceration.

Answer and Explanation

The Correct Answer is A

A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.

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Correct Answer is D

Explanation

A. Petroleum jelly can be applied, but it is not the priority action.
B. Using the thumb and index finger to keep the client's mouth open can be unsafe and uncomfortable.
C. A soft toothbrush should be used to prevent injury to the oral mucosa.
D. Turning the client on his side reduces the risk of aspiration during oral care.

A. Inform the client that this drug combination is most effective if the ginkgo biloba is taken twice daily. B. Inform the client that memory problems following valve replacement surgery are common, but temporary. C. Instruct the client that ginkgo biloba interacts with anticoagulant drugs and then check for bruising or bleeding. D. Instruct the client to keep a record of episodes of forgetfulness or memory disturbances to monitor effectiveness.

Correct Answer is C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

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The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Correct Answer is C

Explanation

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