The practical nurse (PN) applies oxygen at 2 liters/minute via nasal cannula to a client with dyspnea. Thirty minutes later the client's oxygen saturation reading is 98% and the client continues to report feeling short of breath. Which action should the PN take?

Rationale:
A. This option is incorrect because assisting the client to cough or deep breathe could increase intra-abdominal pressure and worsen evisceration. Respiratory support should be gentle and only if necessary, avoiding straining.

B. This option is incorrect because holding direct pressure on exposed intestinal tissue can cause tissue damage. The priority is to protect the tissue without applying pressure.

C. This option is incorrect because inserting a PIV is important for fluid resuscitation but is not the immediate action. The PN should first stabilize the wound and notify the surgeon before additional invasive procedures.

D. This option is incorrect because the client should not be transported to the OR until the wound is protected and the surgeon is notified. Immediate unprotected transport can increase the risk of contamination and injury to exposed tissue.

E. This option is correct because covering the wound with sterile gauze soaked in sterile saline maintains tissue viability, prevents contamination, and reduces drying of the exposed intestines. This is the first step in managing evisceration.

F. This option is incorrect because oral intake is contraindicated when evisceration occurs, as the client may require emergency surgery and anesthesia.

G. This option is correct because the surgeon must be notified immediately to prepare for emergency surgical intervention. Timely communication is critical to prevent complications.

H. This option is correct because placing the client in low-Fowler’s with knees bent reduces tension on the abdominal muscles, helping prevent further protrusion of the intestines and promoting comfort while waiting for surgical intervention.

Rationale:
A. Healthcare provider (HCP) notified, client refuses to have blood glucose taken is partially correct but does not include the client’s statement, which is important for accurate and objective documentation.

B. Blood glucose not obtained because client no longer wants to have finger stick is incorrect because it is subjective and does not include notification of the HCP or the client’s exact words.

C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider (HCP) notified is correct because it objectively documents the client’s refusal, includes the exact words in quotation marks for accuracy, and notes that the HCP was notified, which is required for continuity of care and legal purposes.

D. Healthcare provider (HCP) notified that client is uncooperative and irritable, glucose level not assessed is incorrect because it uses judgmental and subjective language (“uncooperative and irritable”), which is inappropriate for professional documentation.