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. Celecoxib B. Atorvastatin C. Prednisone D. Digoxin

Correct Answer is A

Explanation

Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that can cross-react with sulfa and should be avoided in clients with a sulfa allergy. Atorvastatin, prednisone, and digoxin do not contain sulfa and are safe for clients with a sulfa allergy.

Choice B: Atorvastatin does not contain sulfa and is safe for clients with a sulfa allergy.

Choice C: Prednisone does not contain sulfa and is safe for clients with a sulfa allergy.

Choice D: Digoxin does not contain sulfa and is safe for clients with a sulfa allergy.

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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

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Correct Answer is D

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Correct Answer is A

Explanation

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