Question

A nurse is preforming a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take?

a. Place the client in a supine position.

b. Measure vital signs.

c. Cover the wound with a sterile, saline-moistened dressing.

d. Call for help.

Answer 1

The nurse should call for help when encountering a protruding bowel during a dressing change for a client recovering from a hemicolectomy.

Step-by-step explanation:

The nurse should take the following action: d. Call for help.

1. Call for help: A protruding bowel is a medical emergency that requires immediate intervention. The nurse should call for additional medical staff, such as a surgeon, to assist with the situation.
2. Place the client in a supine position: This action may be necessary after calling for help and under the guidance of the healthcare team. However, it is not the first step to take in this scenario.
3. Measure vital signs: While vital signs are important, they should not be the nurse's first priority in this situation. The nurse should focus on calling for help and providing immediate assistance to the client.
4. Cover the wound with a sterile, saline-moistened dressing: Applying a dressing is not appropriate for a protruding bowel situation. This action may lead to further complications and should not be attempted without proper medical intervention.