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","D","E"]

Explanation

A. Immobility can lead to pressure ulcers due to prolonged pressure on bony prominences.
B. Polyuria is not a common complication of immobility.
C. Diarrhea is not typically associated with immobility; constipation is more common.
D. Immobility can cause contractures of the extremities due to muscle shortening and tightening.
E. Crackles in the lungs can occur due to fluid accumulation and reduced lung expansion associated with immobility.

A. Grilled salmon B. Kidney beans C. Raw spinach D. Peanut butter

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.

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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

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is A

Explanation

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