A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

Check the client’s vital signs.

Inform the client about the need to return to surgery.

Have the client lie supine with knees flexed.

Cover the client’s wound with a moist, sterile dressing.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is A

Explanation

Choice A rationale:

Respects patient autonomy: This response directly addresses the patient's preference and demonstrates respect for their right to make decisions about their own care. It empowers the patient by offering a solution that aligns with their stated wishes.

Promotes patient comfort: By accommodating the patient's preference, the nurse can help to create a more comfortable and trusting environment, which can lead to better patient outcomes.

Protects patient privacy: Personal hygiene care often involves exposure of sensitive body parts and can be a source of embarrassment or anxiety for some patients. Ensuring that the patient is comfortable with the gender of the caregiver helps to protect their privacy and dignity.

Demonstrates cultural sensitivity: While not explicitly stated in the question, it's possible that the patient's preference is rooted in cultural or religious beliefs. Being sensitive to these factors is essential for providing culturally competent care.

Provides a practical solution: This response offers a concrete solution that can be easily implemented, ensuring that the patient's needs are met in a timely and efficient manner.

Choice B rationale:

May be perceived as intrusive: Asking the patient to explain their reasoning could make them feel uncomfortable or defensive. It's important to respect the patient's right to privacy and not pressure them to disclose personal information.

Could delay care: While understanding the patient's reasons may be helpful in some cases, it's not essential for providing appropriate care. Delaying care to gather this information could potentially compromise the patient's well-being.

Choice C rationale:

Dismisses patient's concerns: This response fails to acknowledge the patient's preference and could make them feel unheard or disrespected. It's important to validate the patient's feelings and concerns, even if you don't fully understand them.

May not address underlying issues: The patient's preference may be based on factors that are not related to the AP's competence or experience. Simply stating the AP's qualifications is unlikely to resolve the patient's concerns.

Choice D rationale:

Defers responsibility: While informing the charge nurse may be necessary for logistical reasons, it's important for the nurse to take ownership of the situation and address the patient's concerns directly. Deferring to another staff member could make the patient feel like their concerns are not being taken seriously.

May delay care: Involving additional staff members could potentially delay the patient's care. It's more efficient to address the patient's preference directly, if possible.

A. Obtain vital signs. B. Notify the registered nurse. C. Administer diphenhydramine. D. Stop the transfusion.

Correct Answer is D

Explanation

Rationale for Choice A: Obtain vital signs

While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.

Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.

Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.

Rationale for Choice B: Notify the registered nurse

Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.

The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.

Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.

Rationale for Choice C: Administer diphenhydramine

Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.

The priority is to halt the infusion of the blood product that is potentially causing the reaction.

Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.

Rationale for Choice D: Stop the transfusion

This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.

These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.

It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.

By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.

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A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

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