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 A

Explanation

A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.

B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.

C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.

D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.

A. Exposure to radiation B. Family history C. Another type of cancer D. Genetic mutation

Correct Answer is A

Explanation

A. Exposure to radiation - Exposure to high levels of radiation is a known risk factor for developing CML. Historical data, such as from atomic bomb survivors, show a higher incidence of leukemia, including CML, among those exposed to radiation.

B. Family history - CML is generally not associated with a significant familial risk. It is more commonly linked to acquired genetic mutations rather than inherited predispositions.

C. Another type of cancer - Having another type of cancer does not directly increase the risk of developing CML. However, treatments for other cancers, like radiation therapy, might increase risk.

D. Genetic mutation - The development of CML is associated with a specific acquired genetic mutation known as the Philadelphia chromosome (translocation between chromosomes 9 and 22), rather than inherited genetic mutations.

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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

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