On day four postop following an open abdominal surgery, the patient develops a cough. During an assessment, the patient coughs, and the wound dehisces. The nurse notes intestinal loops are visible outside of the wound. Which initial intervention by the nurse is appropriate?

Cover the intestines with gauze soaked in warmed sterile normal saline. Following an evisceration, the nurse must protect the integrity of the intestines by covering them with gauze soaked in warmed sterile normal saline. The nurse places the patient in low Fowler’s, not high Fowler’s, with the knees flexed. The nurse stays with the patient and recruits a colleague to contact the surgeon and attending physician; this is not the nurse’s initial action. The patient should be encouraged to relax the abdominal muscles, not engage them, to prevent strangulation of the eviscerated intestines.

On day four postop following an open abdominal surgery, the patie...

Category: Physiological Adaptation
Difficulty: 5

Topics: Communication & Documentation Disease Prevention Gastrointestinal Respiratory

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The unconscious patient presents with the following respiratory pattern: The nurse anticipates further testing will reveal which condition?

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The patient is hunched over in the emergency department waiting room, breathing slowly and shallowly. His wife insists he “took something”. The man has bradypnea and marked miosis. Which intoxicant does the nurse suspect?

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The 75-year-old patient presents to the emergency department complaining of a severe headache that is localized behind the right eye. The patient is nauseous and vomits upon standing. While wearing glasses, the visual acuity is 20/25 in the left eye and 20/110 in the right (records show it is normally also 20/25 corrected). Her left pupil is equal, round, and reactive to light and accommodation; it is measured at 3 mm. Her right pupil reacts only minimally to light and measures at 5 mm; it is round. The provider palpates the eye and reports that it is tense. Her heart rate is 102 bpm and blood pressure is 118/84 mmHg. The nurse anticipates providing which intervention first?

Question Type: Multiple Choice - Select One
Difficulty: 10

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