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 D

Explanation

A. While some clients with chronic pain may develop coping mechanisms, this does not mean that measures for relief are unnecessary. Pain management is still crucial for maintaining quality of life.
B. Opioid-based analgesics can be effective for some individuals with chronic pain, but their effectiveness can vary and they may not always be the best option due to potential side effects and the risk of dependence.
C. Chronic pain can be challenging to assess, but the perception and expression of pain are subjective and can vary greatly among individuals. Constant complaints of pain do not necessarily mean the pain intensity is difficult to assess; rather, it indicates the need for thorough pain evaluation.
D. Chronic pain often does not trigger the same physiological responses as acute pain. Therefore, vital signs such as heart rate, blood pressure, and pulse rate may remain normal even while the client is experiencing pain. This can make it more challenging to assess the presence and intensity of pain solely based on these parameters.

A. Enteral B. Topical C. Intravenous D. Intramuscular

Correct Answer is C

Explanation

A. Enteral administration involves the gastrointestinal tract, which has a slower absorption rate.
B. Topical administration involves absorption through the skin, which is also slower.
C. Intravenous (IV) administration delivers medication directly into the bloodstream, providing the fastest rate of absorption.
D. Intramuscular (IM) administration is faster than enteral and topical but slower than intravenous.

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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

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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