The practical nurse (PN) begins to suction a client's oropharynx as seen in the picture. Which action should the PN take next?

Rationale:
A. This option is incorrect because while the client may benefit from prayer, inviting staff and family to pray without confirming the client’s preferences may not align with their spiritual or cultural beliefs. The client’s autonomy and specific spiritual needs should guide the intervention.

B. This option is incorrect because encouraging hope for recovery is inappropriate in hospice care, where the focus is on comfort, dignity, and end-of-life support rather than curative treatment. It could cause distress or give false expectations.

C. This option is correct because contacting the facility’s chaplain ensures the client receives professional spiritual support in accordance with their expressed readiness to make peace with God. Chaplains are trained to provide guidance, comfort, and ritual support that respects the client’s beliefs and end-of-life wishes.

D. This option is incorrect because relying on the family to contact clergy may delay timely spiritual support. The PN should proactively facilitate access to spiritual care resources to address the client’s immediate needs.

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.