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 B
Explanation
Choice A rationale
The glomerular filtration rate (GFR) does not recover during the oliguric phase of acute kidney injury (AKI). Recovery of GFR typically occurs during the recovery phase.
Choice B rationale
During the oliguric phase of AKI, urine output is typically less than 400 mL per 24 hours.
Choice C rationale
Renal function is not reestablished during the oliguric phase of AKI. This typically occurs during the recovery phase.
Choice D rationale
Blood urea nitrogen (BUN) and creatinine levels do not decrease during the oliguric phase of AKI. These levels typically increase due to decreased kidney function.
Correct Answer is B
Explanation
Choice A rationale
Sliced ham with green salad might not be the best choice for a patient with diverticulitis. Ham is a processed meat, which is generally high in fat and can be difficult to digest, potentially irritating the digestive tract. Moreover, a green salad, while generally healthy, can be high in fiber, especially if it includes raw vegetables. During a diverticulitis flare-up, a low-fiber diet is recommended.
Choice B rationale
Grilled chicken breast with white rice is an excellent choice for a patient with diverticulitis. Chicken is a lean protein that is easy to digest. White rice is a low-fiber carbohydrate that is
also easy on the digestive system. This meal is consistent with the dietary recommendations for diverticulitis during the recovery phase, which includes low-fiber foods.
Choice C rationale
A turkey sandwich with celery sticks might not be suitable for a patient with diverticulitis. While turkey is a lean protein, celery sticks are high in fiber and can be difficult to digest, potentially irritating the digestive tract.
Choice D rationale
Pork tenderloin with green peas might not be the best choice for a patient with diverticulitis. Although pork tenderloin is a lean meat, green peas are high in fiber and can be difficult to digest, potentially irritating the digestive tract.
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