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
Explanation
Choice A reason: Alcohol can trigger a gout attack because it increases the production and decreases the excretion of uric acid, which is the substance that causes inflammation and pain in the joints. Alcohol also dehydrates the body, which can worsen the symptoms of gout.
Choice B reason: Fruit juice is not a beverage that can trigger a gout attack. Fruit juice contains natural sugars and antioxidants, which may have a beneficial effect on the uric acid levels and the inflammation in the body. However, fruit juice should be consumed in moderation, as excess sugar intake can lead to weight gain and other health problems.
Choice C reason: Milk is not a beverage that can trigger a gout attack. Milk contains protein and calcium, which may help lower the uric acid levels and the risk of gout. Milk also has antiinflammatory properties, which may reduce the pain and swelling in the joints.
Choice D reason: Coffee is not a beverage that can trigger a gout attack. Coffee contains caffeine and antioxidants, which may have a protective effect on the uric acid levels and the inflammation in the body. Coffee also has a diuretic effect, which may help flush out the excess uric acid from the kidneys.
Correct Answer is C
Explanation
Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.
Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.
Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.
Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.
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