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 D

Explanation

NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.

Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.

It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.

Rationale for Choice B:

Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.

Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.

Rationale for Choice C:

Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.

While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.

The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:

Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.

Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate

Crackles in the lungs Shortness of breath Hypoxia

Early identification of these signs is crucial for prompt intervention and prevention of serious complications.

A. Crackles B. Stridor C. Strong cough D. Deep breathing

Correct Answer is B

Explanation

Choice B rationale:

Stridor is a high-pitched, whistling sound that is heard during inspiration. It is a sign of upper airway obstruction, indicating a potentially life-threatening complication that requires immediate intervention.

Here's a detailed explanation of why stridor is the most concerning finding and why the other choices are not as indicative of a serious problem:

Stridor:

Mechanism: Stridor occurs when there is narrowing or obstruction of the upper airway, typically at the level of the larynx or trachea. This narrowing can be caused by various factors, including:

Laryngospasm: A sudden constriction of the vocal cords, often triggered by irritation or inflammation. Post-extubation edema: Swelling of the tissues in the airway after removal of the endotracheal tube.

Mucus plugging: Accumulation of thick secretions in the airway, which can partially block airflow.

Vocal cord dysfunction: Impairment of the vocal cords' movement, which can affect their ability to open and close properly.

Significance: Stridor is a serious sign because it indicates that airflow is significantly restricted. If left untreated, upper airway obstruction can lead to hypoxia (low oxygen levels) and respiratory failure.

Nursing intervention: If stridor is present, the nurse should immediately notify the provider and prepare for potential interventions to secure the airway, such as:

Reintubation: Reinserting the endotracheal tube to bypass the obstruction.

Nebulized racemic epinephrine: Medication to reduce swelling in the airway.

Heliox: A mixture of helium and oxygen that can improve airflow through a narrowed airway. Steroids: Medications to reduce inflammation in the airway.

Crackles (Choice A):

Description: Crackles are rattling, crackling sounds heard in the lungs, often during inspiration. They are typically associated with lower airway problems, such as pneumonia or pulmonary edema.

Significance: While crackles can indicate respiratory issues, they are not as immediately concerning as stridor in the context of post-extubation care.

Strong cough (Choice C):

Significance: A strong cough is generally a positive sign after extubation, as it indicates that the patient is able to clear secretions from their airway effectively.

Deep breathing (Choice D):

Significance: Deep breathing is also a positive sign, as it promotes lung expansion and oxygenation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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