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 C

Explanation

A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.

A. Grilled salmon B. Kidney beans C. Raw spinach D. Peanut butter

Correct Answer is A

Explanation

A. Grilled salmon is high in protein and also provides omega-3 fatty acids, which are beneficial for wound healing.
B. Kidney beans are a good source of protein but not as high as salmon.
C. Raw spinach is nutritious but low in protein.
D. Peanut butter contains protein, but not as much as salmon and may not be as easily digestible for some patients.

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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

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