A client is postoperative day 1 and reports a sudden increase in bloodtinged liquid draining from his incision after feeling a popping sensation. What is the nurse's next action?
Send the client back to surgery
Call the provider immediately
Assess the wound for signs of dehiscence
Prepare to culture the wound
The Correct Answer is C
Choice A reason: Send the client back to surgery is not the nurse's next action, because it is premature and inappropriate. Sending the client back to surgery requires a medical order and a clear indication of the need for surgical intervention. The nurse cannot make this decision without first assessing the wound and contacting the provider.
Choice B reason: Call the provider immediately is not the nurse's next action, because it is not the most urgent and relevant. Calling the provider immediately is an important action, but it should be done after assessing the wound and gathering the necessary data. The nurse should be able to report the findings of the wound assessment, such as the size, shape, color, amount, and type of drainage, as well as the vital signs, pain level, and mental status of the client.
Choice C reason: Assess the wound for signs of dehiscence is the nurse's next action, because it is the most urgent and relevant. Assessing the wound for signs of dehiscence is a priority action, because it can identify the cause and severity of the problem. Dehiscence is a complication that occurs when the surgical incision splits open or separates, which can cause increased drainage, pain, and infection. Dehiscence can be caused by factors such as infection, poor wound healing, excessive strain, or trauma. Dehiscence can be detected by inspecting the wound for gaps, edges, or protrusions.
Choice D reason: Prepare to culture the wound is not the nurse's next action, because it is not the most urgent and relevant. Preparing to culture the wound is a possible action, but it should be done after assessing the wound and contacting the provider. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound requires a medical order and a sterile technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
Correct Answer is A
Explanation
Choice A reason: Flushing the exposed skin with water is the first action that the nurse should take if they are stuck by a needle. This is to reduce the amount of blood or body fluid that may have entered the wound and to prevent infection. The nurse should flush the skin for at least 15 minutes and avoid using soap, antiseptic, or bleach as they may damage the skin or increase the risk of infection.
Choice B reason: Reporting the exposure is the second action that the nurse should take after flushing the exposed skin with water. This is to inform the supervisor, the occupational health department, or the infection control team about the incident and to initiate the postexposure protocol. The nurse should provide the details of the exposure, such as the type and source of the needle, the depth and location of the wound, and the status of the source patient.
Choice C reason: Seeking medical attention is the third action that the nurse should take after reporting the exposure. This is to receive a medical evaluation and treatment, such as testing, prophylaxis, counseling, and followup. The nurse should consult a health care provider as soon as possible and follow the recommendations for preventing or treating any potential infections, such as hepatitis B, hepatitis C, or HIV.
Choice D reason: Completing an incident report is the last action that the nurse should take after seeking medical attention. This is to document the exposure and the actions taken and to identify the causes and the preventive measures for the future. The nurse should fill out the incident report form accurately and objectively and submit it to the appropriate authority. The incident report is not a part of the client's record and should not be mentioned in the client's chart.
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