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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Eating a high fiber diet will reduce my risk for developing skin cancer." There is no evidence that a high-fiber diet specifically reduces the risk of skin cancer. This statement indicates a misunderstanding and a need for further teaching.

B. "I should check my skin monthly for any changes." Regular self-examinations are recommended to detect early signs of skin cancer.

C. "I should use sunscreen even on cloudy days." UV rays can penetrate clouds, so using sunscreen on cloudy days is an important preventive measure.

D. "I should avoid the use of tanning booths." Tanning booths increase the risk of skin cancer, so avoiding them is a correct preventive action.

A. Hemoglobin level B. Fluid intake C. Temperature D. Skin color

Correct Answer is C

Explanation

A. Hemoglobin level:While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.

B. Fluid intake:Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.

C. Temperature:A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.

D. Skin color:Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

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?

A nurse is caring for a client with a chronic wound. Which of the following is a potential complication of a chronic wound?