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. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.

B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.

C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.

D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.

A. increased heart rate B. Increase hematocrit C. increased blood pressure D. Increased temperature E. increased respiratory rate

Correct Answer is ["A","C","E"]

Explanation

A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.

B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.

C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.

D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.

E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.

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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 in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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