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. Fresh-frozen plasma can be administered via peripheral access.
B. Dextrose 10% in water can typically be administered via peripheral access.
C. 0.9% sodium chloride (normal saline) can be administered via peripheral access.
D. Parenteral nutrition formula, particularly if it is hyperosmolar, often requires central venous access due to the high concentration of glucose and nutrients, which can irritate peripheral veins and require a more stable infusion rate.
Correct Answer is C
Explanation
A. Stage II pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
B. Stage I pressure ulcers are characterized by intact skin with non-blanchable redness.
C. Stage III pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
D. Stage IV pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.