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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?

A.

Place the head of the client's bed flat with the client's legs extended.

B.

Apply butterfly strips to approximate the wound edges.

C.

Apply pressure directly to the wound for 15 min.

D.

Place a sterile, saline-soaked dressing on the wound.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

  • Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
  • Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
  • Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
  • Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
  • Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

Correct Answer is A

Explanation

Rationale:

A. Check the cords of the IV pump for fraying: Inspecting electrical cords for fraying or damage is an important safety step before use. Damaged cords can cause electrical shock, fire hazards, or equipment malfunction, so this helps ensure safe operation.

B. Remove the safety inspection sticker before plugging in the IV pump: Safety inspection stickers indicate that the device has passed electrical and functional safety checks. Removing them would eliminate visible proof of inspection and is not necessary for safe use.

C. Ensure that the electric outlet has two prongs for the IV pump: Medical equipment such as IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets do not provide this grounding protection.

D. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord can damage the internal wires and increase the risk of electrical hazards. The correct method is to grasp the plug itself when disconnecting from the outlet.

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