A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Apply a debriding agent.

Apply steri-strips.

Obtain a wound culture.

Remove every other suture.

Answer and Explanation

The Correct Answer is C

A.   Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B.   Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C.   Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D.   Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

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Correct Answer is C

Explanation

A. This action involves assessing how the client’s current symptoms and manifestations align with the criteria of the nursing problems identified. By doing this, the nurse can ensure that the goals set are directly related to addressing these specific issues.
B. While prioritizing nursing actions is important for immediate care needs, listing these actions is more related to the implementation phase rather than the goal-setting phase. Goals are broader and focus on what outcomes are desired for the client, while nursing actions are specific steps taken to achieve those goals.
C. Reviewing the priority nursing problems helps in identifying the most urgent issues that need to be addressed. This review is essential for setting appropriate goals, as it ensures that the goals reflect the most pressing needs of the client.
D. Ensuring that prescribed treatments have been initiated is part of the implementation phase of care. While it is important for the overall management of the client’s health, this step does not directly involve goal setting.

A. Revise clinical practice guidelines. B. Engage staff in evidence based practice. C. Evaluate effectiveness of the change. D. Consult with a clinical nursing expert.

Correct Answer is C

Explanation

A. Revising clinical practice guidelines might be necessary in the long term if the new approach becomes widely accepted and proven effective. However, this action is typically part of a broader, organizational process that follows initial implementation and evaluation.
B. Engaging staff in evidence-based practice is crucial for successful implementation of the new approach. This involves educating and training staff on the new methods, ensuring they understand and support the change, and integrating the new practices into daily routines.
C. Evaluating the effectiveness of the change is a critical next step. After implementing a new approach, it is essential to assess whether it achieves the desired outcomes and improves client care. This evaluation involves monitoring and analyzing results to determine if the change is beneficial and meets the intended goals.
D. Consulting with a clinical nursing expert can be helpful for advice and guidance during the implementation process. However, this action is typically part of the initial planning and decision-making stages rather than the immediate next step after gathering evidence.

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A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is C

Explanation

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

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