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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Interpret the client's need for pain medication: Determining the need for analgesia requires professional nursing judgment and assessment, which is outside the AP’s scope of practice. The nurse must evaluate pain and make medication decisions.
B. Change a sterile dressing on a client's open incisional wound: Sterile dressing changes involve invasive procedures and assessment of wound healing, which are nursing responsibilities. APs can assist with non-sterile care but cannot perform sterile interventions independently.
C. Educate a client on the use of a glucometer: Patient education involves teaching, assessing understanding, and clinical judgment, all of which require nursing expertise. APs can reinforce teaching but cannot independently instruct clients on medical device use.
D. Perform cardiopulmonary resuscitation on a client: CPR is a basic life-saving procedure that APs are trained and authorized to perform in emergencies. This task falls within the AP’s scope of practice and can be done under general supervision until advanced help arrives.
Correct Answer is A
Explanation
A. "Bacterial meningitis can be prevented with immunization": Vaccines such as the meningococcal, pneumococcal, and Haemophilus influenzae type b (Hib) vaccines significantly reduce the risk of bacterial meningitis. Immunization is a primary preventive measure, especially for high-risk populations, including children, adolescents, and certain adults.
B. "Bacterial meningitis is an infection that causes inflammation of the sinus cavity.": Bacterial meningitis causes inflammation of the meninges, which are the protective membranes covering the brain and spinal cord, not the sinuses. Confusing the site of infection can lead to inappropriate assessment and treatment.
C. "Bacterial meningitis is spread by contaminated food or water; therefore, infection is unlikely": This statement is incorrect because bacterial meningitis is typically spread through respiratory droplets, close contact, or asymptomatic carriers, not through food or water.
D. "Bacterial meningitis rarely occurs in young adults unless their immune system is suppressed.": Young adults, particularly those in communal settings like college dorms or military barracks, are at increased risk regardless of immune status. Immunocompetent individuals can still acquire bacterial meningitis.
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