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 C

Explanation

A. Packed RBCs - These are used to treat anemia or significant blood loss but do not address the clotting deficiency in hemophilia.

B. Fresh frozen plasma - This contains all clotting factors, but in hemophilia A, specifically replacing factor VIII is more effective and targeted.

C. Recombinant - Recombinant factor VIII is a synthetic form of the clotting factor that patients with hemophilia A are deficient in. It is used to increase factor VIII levels before procedures to prevent excessive bleeding.

D. Prophylactic antibiotics - These are used to prevent infection but do not help in managing the bleeding risks associated with hemophilia.

A. Electrolyte abnormalities B. Altered hemoglobin ATC C. Psychological distress D. Fluid volume overload

Correct Answer is C

Explanation

A. Electrolyte abnormalities - These are not typically a direct complication of chronic wounds unless they are associated with severe infections or extensive fluid loss, which is uncommon.

B. Altered hemoglobin A1C - While chronic wounds are common in diabetics, the wound itself does not directly alter hemoglobin A1C; this test measures long-term blood glucose control.

C. Psychological distress - Chronic wounds can lead to significant emotional and psychological stress due to prolonged treatment, appearance issues, and limitations in activities.

D. Fluid volume overload - This is not a direct complication of chronic wounds. Chronic wounds might cause fluid loss due to exudate, but not fluid overload.

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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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