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.
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Related Questions
Correct Answer is C
Explanation
A. "To place my leg under a heat lamp every 3 hours." Using a heat lamp can cause burns and uneven heating, which is not recommended for cellulitis.
B. "I will keep a heating pad on the calf of my right leg when I am lying down." Continuous heat application can cause burns and damage tissues, especially in clients with impaired sensation or circulation.
C. "I will wrap a warm, wet towel around my right calf every 4 hours." Using a warm, wet towel ensures that heat is evenly distributed and provides moist heat, which can help increase blood flow and promote healing in cellulitis.
D. "I will sit on the side of the tub and soak my right leg two times every day." Soaking the leg may not maintain consistent warmth and could also introduce the risk of infection if the water is not clean.
Correct Answer is C
Explanation
A. Elevate the limb and apply ice. Elevating the limb and applying ice can help reduce blood flow to the area and minimize swelling. However, it is not the immediate priority in managing active, profuse bleeding.
B. Apply a tourniquet just below the elbow. A tourniquet should be a last resort due to the risk of cutting off blood flow and potential limb damage. It's typically used in life-threatening situations where other methods fail to control bleeding.
C. Apply direct pressure over the wound. The immediate priority for controlling profuse bleeding is to apply direct pressure to the wound to stop or reduce the bleeding. This is a standard first-line intervention in hemorrhage management.
D. Clean the wound. Cleaning the wound is important to prevent infection, but it is not the first priority when dealing with active, profuse bleeding.
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