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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Physician assistants typically assist with medical diagnoses and treatment plans, not rehabilitation.
B. Physical therapists focus on physical movement and rehabilitation, not typically assisting with activities of daily living such as feeding.
C. Occupational therapists specialize in helping individuals with daily activities, making them the appropriate referral for this client's needs.
D. Social workers typically provide assistance with psychosocial support and community resources, which may be needed but are not as directly related to the client's physical limitations.
Correct Answer is D
Explanation
A. Medications should be diluted as per pharmacy recommendations, not arbitrarily with 10 mL of tap water.
B. The head of the bed should be elevated to at least 30-45 degrees during and after feeding to prevent aspiration.
C. Medications should not be mixed together to avoid interactions unless recommended by the pharmacy.
D. Flushing the NG feeding tube with 30 mL of water immediately following medication administration ensures that the medication has cleared the tube and prevents clogging.
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