A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent.

Which of the following risk factors should the nurse include as the best predictor of future violence?

Partial separation of the upper part of the incisional line.

This is a sign of wound dehiscence, which is a serious complication that occurs when the edges of a surgical incision separate and the underlying tissues are exposed.

Wound dehiscence can lead to infection, bleeding, and evisceration (protrusion of internal organs through the incision). The nurse should report this finding to the provider immediately and cover the wound with a sterile dressing moistened with sterile saline solution.

Choice A is wrong because mild swelling under the sutures near the incisional line is a normal finding in the early stages of wound healing. It does not indicate infection or dehiscence unless accompanied by other signs such as redness, warmth, pain, or purulent drainage.

Choice B is wrong because crusting of exudate on the incisional line is also a normal finding that indicates the formation of a scab.

A scab protects the wound from infection and helps it heal faster. The nurse should not remove the scab unless instructed by the provider.

Choice D is wrong because pink-tinged coloration on the incisional line is another normal finding that shows healthy granulation tissue.

Granulation tissue is new tissue that fills in the wound and helps it close. It is usually pink or red and moist.

The nurse should follow these general tips for postoperative abdominal incision care:

• Always wash your hands before and after touching your incisions.
• Inspect your incisions and wounds every day for signs your healthcare provider has told you are red flags or concerning.
• Look for any bleeding.

If the incisions start to bleed, apply direct and constant pressure to the incisions.

• Avoid wearing tight clothing that might rub on your incisions.
• Try not to scratch any itchy wounds.
• You can shower starting 48 hours after your operation but no scrubbing or soaking of the abdominal wounds in a tub.
• After the initial dressing from the operating room is removed, you can leave the wound open to air unless there is drainage or you feel more comfortable with soft gauze covering the wound.
• Surgical glue (Indermil) will fall off over a period of up to 2-3 weeks. Do not put any topical ointments or lotions on the incisions.
• Do not rub over the incisions with a washcloth or towel.
• No tub baths, hot tubs, or swimming until evaluated at your clinic appointment.

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

• Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
• Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
• Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
• Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
• Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.