A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?
Place the head of the client's bed flat with the client's legs extended.
Apply butterfly strips to approximate the wound edges.
Apply pressure directly to the wound for 15 min.
Place a sterile, saline-soaked dressing on the wound.
The Correct Answer is D
Rationale:
A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.
B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.
C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.
D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
• Macrosomia: Post-term infants (≥ 42 weeks) are at higher risk of excessive birth weight due to prolonged nutrient exposure in utero. Larger infants are prone to birth trauma, shoulder dystocia, and hypoglycemia after delivery.
• Meconium aspiration syndrome: Thick green amniotic fluid indicates meconium passage in utero, likely due to fetal stress from prolonged labor and late decelerations. Inhalation of meconium-stained fluid at birth can cause airway obstruction, chemical pneumonitis, and respiratory distress.
Rationale for Incorrect Choices:
• Bronchopulmonary dysplasia: This chronic lung disease is typically a complication in premature infants requiring prolonged mechanical ventilation and high oxygen concentrations, not in post-term newborns.
• Intraventricular haemorrhage: This complication is primarily seen in premature infants with fragile germinal matrix vessels; it is uncommon in term or post-term neonates unless there is severe birth trauma or asphyxia.
Correct Answer is D
Explanation
Rationale:
A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.
B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.
C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.
D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.
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