A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
Check the client's vital signs.
Cover the wound with a moist, sterile gauze dressing.
Assess the client's pain level.
Obtain a culture and sensitivity of the wound drainage
The Correct Answer is B
A. Check the client's vital signs. While vital signs are important for overall assessment, the immediate priority when faced with wound dehiscence is to protect the wound and prevent further contamination or damage.
B. Cover the wound with a moist, sterile gauze dressing. The first priority is to cover the wound with a moist, sterile dressing to protect it from infection and to manage the drainage. This helps in creating a barrier to prevent contamination and supports the wound environment for healing.
C. Assess the client's pain level. Pain assessment is important but not the immediate priority in this case. Managing the wound and preventing further complications is more critical.
D. Obtain a culture and sensitivity of the wound drainage. While obtaining a culture is important to identify any infection, it is not the first action. Protecting the wound from further contamination comes first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.
B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.
C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.
D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.
Correct Answer is B
Explanation
A. Consume foods high in potassium: Potassium is important for ear health, but there is no direct evidence that high-potassium foods alone reduce the risk of hearing loss.
B. Avoid smoking tobacco products: Smoking is associated with an increased risk of hearing loss due to its negative effects on blood flow to the cochlea and the auditory nerve. Avoiding smoking can reduce the risk of hearing damage.
C. Increase oral intake of water: While staying hydrated is good for overall health, it does not specifically impact hearing loss risk.
D. Limit alcohol to two drinks daily: Excessive alcohol consumption can affect hearing, but moderation is not directly associated with preventing hearing loss as effectively as avoiding smoking.
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