A nurse is assessing a client who is immediately postoperative following abdominal surgery. The nurse notes serosanguineous drainage on the dressing. Which of the following actions should the nurse take?
Remove the surgical dressing and obtain a culture.
Irrigate the incision with saline.
Clean the wound with hydrogen peroxide.
Mark the outline of the drainage.
The Correct Answer is D
A. Remove the surgical dressing and obtain a culture: Removing the dressing immediately is unnecessary for routine serosanguineous drainage, which is a normal finding in the early postoperative period. Cultures are only indicated if there are signs of infection such as purulent drainage, redness, or odor.
B. Irrigate the incision with saline: Irrigation is not required for normal serosanguineous drainage and may disrupt the healing process. It is reserved for wounds with debris, infection, or specific provider orders.
C. Clean the wound with hydrogen peroxide: Hydrogen peroxide can damage healthy tissue and delay healing. It is not indicated for routine postoperative care and should be avoided for normal drainage.
D. Mark the outline of the drainage: Marking the outline of the drainage allows the nurse to monitor for changes in amount and size over time. Tracking progression helps identify potential complications such as excessive bleeding or infection and supports timely interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to take sips of diluted fruit juice: Offering small amounts of juice may help introduce oral intake gradually, but it is not the first step. Ensuring the client can safely swallow is essential before providing any oral fluids to prevent aspiration and other complications.
B. Give the client a pureed diet: Transitioning to a pureed diet is part of advancing nutrition after confirming that the client can swallow safely. Starting this too early without assessing swallowing ability can increase the risk of choking or aspiration.
C. Check the client's swallowing reflex: Assessing the swallowing reflex is the priority when tapering a client from TPN. Safe oral intake depends on intact swallowing function, and identifying any deficits early prevents aspiration, aspiration pneumonia, or other serious complications during the transition to oral nutrition.
D. Provide the client with a full liquid diet: A full liquid diet is a step in progressing from TPN to oral intake, but it should only be introduced after confirming the client can swallow safely. Skipping the assessment of the swallowing reflex could place the client at risk for airway compromise.
Correct Answer is D
Explanation
A. Make referrals to support services: Referrals to social, medical, or mental health support are part of the response and recovery phases, focusing on addressing ongoing client needs after the disaster occurs, rather than planning.
B. Coordinate care in shelters: Coordinating care in shelters is an activity performed during the response phase, when the disaster has already occurred and immediate client needs must be addressed. It is not part of pre-event planning.
C. Triage injured individuals: Triage occurs during the response phase to prioritize treatment based on injury severity. This action is reactive to actual casualties and is not part of the planning phase.
D. Participate in practice drills: Engaging in disaster preparedness drills is a key component of the planning phase. Drills help identify gaps in emergency protocols, improve staff readiness, and ensure effective coordination during an actual mass casualty incident.
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