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 D
Explanation
A. Concerns about amenorrhea and breast atrophy are more commonly associated with anorexia nervosa.
B. Refusal to eat is more characteristic of anorexia nervosa.
C. Refusal to exercise is not typically associated with bulimia nervosa.
D. Binge gorging with purging by vomiting is a hallmark behavior of bulimia nervosa, where individuals consume large amounts of food and then attempt to eliminate the excess calories through purging methods such as vomiting.
Correct Answer is D
Explanation
A. Vitamin B1 (thiamine) is a water-soluble vitamin.
B. Vitamin B12 is a water-soluble vitamin.
C. Vitamin C is a water-soluble vitamin.
D. Vitamin A is a fat-soluble vitamin, along with vitamins D, E, and K. Clients with pancreatitis may have difficulty absorbing fat-soluble vitamins due to impaired pancreatic function.
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