The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Cover the bowel with a sterile saline dressing.

Raise the patient up to a high Fowler's position.

Call the RN.

Turn the patient to the side of the evisceration.

Answer and Explanation

The Correct Answer is A

A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.

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Correct Answer is A

Explanation

A. Grilled salmon is high in protein and also provides omega-3 fatty acids, which are beneficial for wound healing.
B. Kidney beans are a good source of protein but not as high as salmon.
C. Raw spinach is nutritious but low in protein.
D. Peanut butter contains protein, but not as much as salmon and may not be as easily digestible for some patients.

A. Assistance with endotracheal intubation B. Administration of protamine sulfate C. Administration of naloxone (Narcan) D. Administration of oxygen

Correct Answer is C

Explanation

A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.

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The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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