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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Alcohol use disorder. While alcohol use disorder can lead to various health issues, it is not a direct cause of hearing loss.

B. Prolonged exposure to loud noises. Prolonged exposure to loud noises is a well-known risk factor for noise-induced hearing loss. This includes occupational noise exposure and listening to loud music.

C. Exposure to environmental toxins. Some environmental toxins, like certain chemicals and heavy metals, can lead to ototoxicity, which can damage the auditory system and cause hearing loss.

D. Contact with excessive heat. Excessive heat exposure is not directly linked to hearing loss. Hearing loss is more related to factors like noise exposure, ototoxic substances, and infections.

A. [Select All that Apply) B. Mood changes C. Mobility challenges D. Shortness of breath E. Sleep disturbance

Correct Answer is ["A","B","C","D"]

Explanation

A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.

B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.

C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.

D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.

E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?

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