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. Anorexia and malnutrition - While these may occur due to chemotherapy, they are not directly caused by myelosuppression.

B. Diarrhea and dehydration - These symptoms might be side effects of chemotherapy but are not specific to myelosuppression.

C. Bleeding from the gums - Myelosuppression can lead to thrombocytopenia (low platelet count), increasing the risk of bleeding, including from gums and other mucous membranes.

D. Full body alopecia - Alopecia is a common side effect of chemotherapy but is not related to myelosuppression.

A. Heart rate B. Weight C. Urine output D. BP

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.

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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 caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Correct Answer is A

Explanation

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