A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

The correct answer is Choice D: Cover the client's wound with a moist, sterile dressing.

Choice D rationale: In the case of a client with a bowel protrusion from an abdominal incision, the immediate priority is to protect the exposed bowel and minimize the risk of further damage or infection. Covering the wound with a moist, sterile dressing serves to maintain tissue viability, prevent dehydration, and provide a protective barrier against contamination. This intervention preserves the integrity of the exposed bowel while awaiting further medical or surgical management.

Choice A rationale: Checking the client's vital signs is an essential aspect of postoperative care and may be indicative of the client's overall status, but it is not the first action in the case of bowel evisceration. Immediate attention should be directed towards protecting the exposed bowel, with vital signs being monitored closely thereafter to ensure the client's stability.

Choice B rationale: Informing the client about the need for a return to surgery is an important step in the client's care, as it allows for informed consent and understanding of the situation. However, in this scenario, the priority is to address the immediate issue of bowel exposure and provide initial care to the compromised tissue. Once the exposed bowel is appropriately managed, the client should be informed about the potential need for further surgical intervention.

Choice C rationale: Positioning the client in a supine position with knees flexed may help reduce abdominal tension and minimize further protrusion, but it is not the immediate action to take when faced with bowel evisceration. The initial focus should be on protecting the exposed bowel through the application of a moist, sterile dressing, followed by measures to optimize the client's position and promote tissue integrity.

The correct answer is Choice A: Refer questions to the nursing supervisor.

Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.

Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.

Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.

Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.