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 B
Explanation
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.
Correct Answer is D
Explanation
A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.
B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.
C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.
D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.
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