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. There is an elevated number of immature thrombocytes - Thrombocytes are platelets, and a shift to the left does not refer to these.

B. There is an elevated number of immature neutrophils (bands) - A "shift to the left" typically refers to an increase in immature neutrophils, also known as bands, in the blood. This often indicates an acute infection or inflammation as the body is producing and releasing more neutrophils to fight an infection.

C. There is an elevated number of mature neutrophils (segs) - An elevated number of mature neutrophils (segmented neutrophils) does not indicate a shift to the left. The term specifically refers to immature forms.

D. There is an elevated number of mature erythrocytes - Mature erythrocytes are red blood cells, and a shift to the left does not pertain to red blood cell counts or maturity.

A. Wash with plain soap and water. B. sit in the sun for 10 min per day. C. Apply moist heat. D. Apply hydrating lotions.

Correct Answer is D

Explanation

A. "Wash with plain soap and water." While cleanliness is important, plain soap can be drying and irritating. Gentle cleansing is better, using products that do not strip the skin of natural oils.

B. "Sit in the sun for 10 minutes per day." Sun exposure can exacerbate radiation dermatitis and should be avoided. The skin needs protection from additional UV damage.

C. "Apply moist heat." Moist heat can further irritate already sensitive skin and is not recommended for treating radiation-induced skin reactions.

D. "Apply hydrating lotions." Hydrating lotions help to soothe and moisturize the skin, promoting healing and alleviating dryness and scaling caused by radiation treatment. Use products specifically recommended for sensitive or radiated skin.

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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?

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Naxlex Comprehensive Predictor Exams

In reviewing a patient’s complete blood count (CBC) results, the nurse notes a "shift to the left." What is the significance of these results?

Correct Answer is B

Explanation

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Correct Answer is D

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