The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
a. Call the RN
b. Cover the bowel with a sterile saline dressing
c. Turn the patient to the side of the evisceration
d. Raise the patient up to a high Fowler position
ANS: B
Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler position to relieve strain on the suture line.
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Qs
What will be an ideal response?
The nurse instructs a patient on the use of a vaginal estrogen/progestin rings (NuvaRing) for contraception. Which patient statement indicates that additional instruction is needed?
A) "I am to take the ring out overnight.". B) "I will leave the ring in place for 3 weeks.". C) "I leave the ring in place during intercourse.". D) "I am to use other birth control if I take the ring out for 4 hours.".
A 63-year-old female client reports that she has been experiencing problems with urinary incontinence. She expresses her frustration about this normal part of aging. Which statement by the nurse will be most correct at this time?
1. "You are correct about aging and incontinence going hand in hand.". 2. "Yes, there are physical changes associated with aging that may predispose you to incontinence, but they are not a normal part of aging.". 3. "I understand you are frustrated about this occurrence.". 4. "You may need to have surgery to manage this problem.".
What is the most common pathophysiologic process that triggers aplastic anemia (AA)?
a. Autoimmune disease against hematopoiesis by activated cytotoxic T (Tc) cells b. Malignancy of the bone marrow in which unregulated proliferation of erythrocytes crowd out other blood cells c. Autoimmune disease against hematopoiesis by activated immunoglobulins d. Inherited genetic disorder with recessive X-linked transmission