A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Ask someone to quickly get an abdominal binder.

Assist the patient in a supine position.

Seat the patient in a nearby chair.

Instruct the patient to pant to reduce abdominal tension.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. Document your findings. B. Assess the patient for any complaints or problems in the wound area. C. Check the setting on the NPWT unit. D. Observe the dressing area when assessing vital signs.

Correct Answer is B

Explanation

Choice A rationale:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

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A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

Correct Answer is B

Explanation

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Chronic wounds that are not healing well may benefit from (Select all that apply.)

The nurse places Dakin solution in a wound to accomplish chemical:

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Superficial wounds heal faster when kept: