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°.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: Applying an estrogen vaginal cream daily is not a risk factor for osteoporosis. In fact, estrogen can help maintain bone density.

Choice B rationale: Including canned sardines in the diet provides calcium and vitamin D, which are beneficial for bone health.

Choice C rationale: Walking 30 minutes per day is a weight-bearing exercise that helps maintain bone density and is beneficial for preventing osteoporosis.

Choice D rationale: Using a beclomethasone inhaler (a corticosteroid) can be a risk factor for osteoporosis, especially if used long-term, as corticosteroids can lead to bone loss.

A. Echinacea B. Flaxseed powder C. Probiotics D. Ginkgo biloba

Correct Answer is D

Explanation

Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

Reasons, why the other choices are not answers, are:

A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.

B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.

C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.

In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?

Correct Answer is D

Explanation

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