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 C
Explanation
The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.
Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.
Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.
Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.
Correct Answer is B
Explanation
BUN 40 mg/dL. Elevated BUN levels can indicate impaired kidney function, which can be a potential adverse effect of long-term NSAID therapy.
Reasons why the other options are not answers:
Option A: Total bilirubin 0.8 mg/dL is a normal value and does not require reporting to the provider.
Option C: PaO2 90 mm Hg is within the normal range and does not require reporting to the provider.
Option D: Hematocrit 45% is within the normal range and does not require reporting to the provider.
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