Gastrointestinal Question #8

Question

While the nurse is assisting a client to eat following abdominal surgery, the client begins to cough forcefully. The nurse observes intestinal evisceration. What is the first action the nurse should perform?

Answers

  1. Document the amount, color, drainage.
    • Rationale:
  2. Cover the intestines with sterile moist dressings.
    • Rationale:
  3. Place the client in low fowler’s position.
    • Rationale:
  4. Call the surgeon.
    • Rationale:

Overview

Explanation

The low fowler’s position will take stress off the abdominal wound and will help minimize further extrusion of the intestines. Option A is incorrect since the nurse should not take time to document without intervening for the client. Option B may seem like the answer, but is incorrect since the position change must be made first, then the nurse may cover the intestines with sterile moist dressings. While option D is also correct action, it is not the first action since the client’s needs must be met first.

Learning Outcomes

Test Taking Tip

Video Rationale