A nurse is caring for a client who is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding. After contacting the rapid response team, which of the following actions should the nurse take next?
Obtain a set of vital signs.
Flex the client's knees and hips.
Apply a moist saline dressing to the area.
Elevate the head of the client's bed 20°.
The Correct Answer is C
The correct answer is c. Apply a moist saline dressing to the area.
Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.
Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.
Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.
Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Limit fluid intake during meals.
Choice A rationale:
Limiting fluid intake during meals can help prevent the stomach from becoming too full, which can make breathing more difficult for someone with COPD.
Choice B rationale:
Eliminating dairy products is not typically recommended for COPD patients unless they have a specific intolerance or allergy. Dairy does not generally affect COPD symptoms.
Choice C rationale:
Consuming three regular meals daily might be challenging for COPD patients who often have reduced appetite and may benefit more from smaller, frequent meals.
Choice D rationale:
Eating lighter, low-calorie foods first is not advisable for COPD patients who need nutrient-dense foods to maintain their energy levels and overall health.
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.
Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.
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