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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Mood changes: Deficiency can cause neurological changes, including depression and mood swings.
B. Mobility challenges: Neuropathy and muscle weakness can lead to mobility issues.
C. Shortness of breath: Anemia from B12 deficiency reduces oxygen delivery, causing dyspnea.
D. Visual deficit: Neurological impairment from B12 deficiency can affect the optic nerve, leading to visual disturbances.
E. Sleep disturbance: This is not a typical manifestation of B12 deficiency and is more likely related to other factors.
Correct Answer is B
Explanation
A. "Vision changes occur suddenly due to complete obstruction of aqueous humor outflow." This describes acute angle-closure glaucoma, not retinal detachment.
B. "Vision changes occur when retinal tissue pulls away from the blood vessels in the eye." Retinal detachment happens when the retina separates from its supporting tissues, including the blood vessels, leading to vision loss.
C. "Vision changes occur when the retina begins to break down and collect bits of debris." This describes age-related macular degeneration, not retinal detachment.
D. "Vision changes occur when the cloudy lens alters the passage of light through the eye." This describes cataracts, not retinal detachment.
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