A nurse is caring for a patient who is postoperative following abdominal surgery.
The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do?
Gently reinsert the bowel back into the patient’s wound.
Place the head of the patient’s bed in the flat position.
Apply moistened sterile gauze to the site.
Position the patient on his left side.
The Correct Answer is C
Choice A rationale
Gently reinserting the bowel back into the patient’s wound is not recommended. This could cause further harm to the patient.
Choice B rationale
Placing the head of the patient’s bed in the flat position is not the best action. This position may not provide the necessary comfort or safety for the patient.
Choice C rationale
Applying moistened sterile gauze to the site is the correct action. This helps to protect the protruding bowel and prevent further contamination until surgical intervention can be performed.
Choice D rationale
Positioning the patient on his left side is not the best action in this situation. It does not directly address the issue of the protruding bowel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lidocaine does not primarily serve to relieve pain when administered intravenously. It is primarily used as an antiarrhythmic agent.
Choice B rationale
Lidocaine does not slow intestinal motility. This is not one of its primary actions.
Choice C rationale
Lidocaine does not dissolve blood clots. It is not an anticoagulant.
Choice D rationale
Lidocaine prevents dysrhythmias. It is an antidysrhythmic medication that delays the conduction in the heart and reduces the automaticity of heart tissue.
Correct Answer is A
Explanation
Choice A rationale
Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.
Choice B rationale
Offering a light snack is not specifically required before administering digoxin.
Choice C rationale
While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.
Choice D rationale
Weighing the patient is not specifically required before administering digoxin.
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