A 65-year-old post-operative patient presents with a sudden opening of their surgical abdominal wound. What is the most appropriate immediate nursing action to take for this patient experiencing wound dehiscence?

Instruct the patient to cough and deep breathe to prevent atelectasis.

Apply a sterile saline dressing and notify the surgeon immediately.

Increase the patient's oral fluid intake to promote healing.

Apply pressure to the wound to stop any bleeding.

Answer and Explanation

The Correct Answer is B

A. Instruct the patient to cough and deep breathe to prevent atelectasis: While coughing and deep breathing are important post-operative interventions to prevent respiratory complications, they are not appropriate actions in the case of wound dehiscence. Encouraging coughing could exacerbate the situation by increasing intra-abdominal pressure.

B. Apply a sterile saline dressing and notify the surgeon immediately: This is the most appropriate immediate action in the event of wound dehiscence. Applying a sterile saline dressing helps protect the exposed tissue and prevent infection, while notifying the surgeon is crucial for further evaluation and intervention. Wound dehiscence is a surgical emergency that requires prompt attention.

C. Increase the patient's oral fluid intake to promote healing: While adequate hydration is important for overall recovery, it is not an immediate action to take in response to wound dehiscence. Addressing the wound itself and notifying the surgical team is the priority in this situation.

D. Apply pressure to the wound to stop any bleeding: While it is important to control bleeding, applying pressure may not be appropriate if there is significant opening or exposure of the internal structures. Instead, the focus should be on covering the wound with a sterile dressing and seeking immediate surgical intervention to assess and manage the dehiscence.

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Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

A. "I should get a longer cord for my telephone." B. "I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "It is a good idea to use the handrails in the bathroom."

Correct Answer is D

Explanation

A. "I should get a longer cord for my telephone.": Longer cords can create tripping hazards, increasing the risk of falls. It is safer to use shorter cords or secure them properly to minimize risks. Keeping cords neatly organized and out of walkways is essential for maintaining a safe environment.

B. "I should use chairs without armrests.": Chairs with armrests can provide additional support for getting in and out of the chair, which can help prevent falls. Using chairs without armrests may make it more difficult to rise safely and could lead to losing balance during the process.

C. "I should place a throw rug over electrical cords.": Throw rugs can create tripping hazards. Placing rugs over electrical cords does not eliminate the risk and could further increase the likelihood of a fall. It's important to keep the area clear of both rugs and cords to promote safety and prevent accidents.

D. "It is a good idea to use the handrails in the bathroom.": Handrails provide stability and support when navigating potentially slippery areas, such as bathrooms, and can significantly reduce the risk of falls. Utilizing handrails allows individuals to maintain their balance and provides reassurance when moving in and out of the tub or shower.

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A 65-year-old post-operative patient presents with a sudden opening of their surgical abdominal wound. What is the most appropriate immediate nursing action to take for this patient experiencing wound dehiscence?

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