The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Cover the bowel with wet sterile gauze

Assist the client into a low-Fowler's position with knees flexed

Assist the client into a side-lying position with knees flexed

Retrieve the crash cart from the nursing station

Call for assistance

Measure the client's inspiratory volume via incentive spirometer

Answer and Explanation

Correct Answer : A,B,E

A: Covering the bowel with sterile gauze moistened with saline protects the exposed tissue and prevents it from drying out.

B: A low-Fowler's position with knees flexed reduces strain on the abdomen and minimizes further protrusion.

C: A side-lying position does not relieve strain on the abdominal incision as effectively as a low-Fowler’s position.

D: Retrieving the crash cart is unnecessary unless there is evidence of impending cardiopulmonary arrest.

E: Calling for assistance is essential to notify the surgical or medical team promptly.

F: Measuring inspiratory volume is irrelevant in this scenario and delays appropriate intervention.

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Correct Answer is A

Explanation

A. The changes in vital signs are within expected ranges post-procedure, so continued monitoring is appropriate.

B. A temperature increase to 99°F is not significant and does not require immediate reporting.

C. No signs of hypovolemia or dehydration warrant increasing IV fluids.

D. A blood pressure decrease to 112/72 mm Hg is minimal and not concerning.

A. increase the infusion rate of Midazolam B. Administer supplemental oxygen via nasal cannula C. Administer naloxone. D. Perform a thorough neurological assessment

Correct Answer is C

Explanation

A. Increasing the infusion would worsen respiratory depression.

B. Supplemental oxygen is supportive but does not address the cause of respiratory depression.

C. Midazolam can cause respiratory depression, and flumazenil (a benzodiazepine antagonist) is the antidote; however, if naloxone is available, it may reverse sedation quickly in emergency scenarios.

D. While neurological assessment is vital, it does not address the immediate issue of respiratory compromise.

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The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A client is brought to post anesthesia care unit (PACU) after an invasive procedure. Based on the two sets of vital signs in the chart tab, which action is most appropriate by the nurse?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

What type of procedural information should be given to a client in preparation for ambulatory surgery? (Select All that Apply)

The nurse is caring for a client in the immediate post-operative period. On assessment, the nurse notes the client's bowels are protruding from the abdominal incision. Which intervention(s) by the nurse are most appropriate at this time? (Select All That Apply]

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