The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

change the surgical dressing immediately to prevent infection.

outline the area of drainage with a pen and mark it with the date and time.

make a note of the drainage on the worksheet to report it at the end of shift.

reinforce the dressing with clean gauze sponges and tape.

Answer and Explanation

The Correct Answer is B

A. Change the surgical dressing immediately to prevent infection. Changing the dressing immediately is unnecessary unless there is a significant issue, such as excessive drainage or signs of infection. Minor drainage can be observed unless there's a need for further intervention.

B. Outline the area of drainage with a pen and mark it with the date and time. This is the correct action to monitor the drainage over time. By marking the area, the nurse can track whether the drainage increases, stays the same, or decreases, which helps in assessing the wound’s status and effectiveness of the surgical dressing.

C. Make a note of the drainage on the worksheet to report it at the end of shift. While documentation is important, it is essential to monitor the drainage immediately after the initial assessment rather than waiting until the end of the shift.

D. Reinforce the dressing with clean gauze sponges and tape. Reinforcing the dressing may be appropriate if drainage is increasing or if the dressing is inadequate, but marking the area first is necessary for accurate tracking.

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Correct Answer is A

Explanation

A. Dehiscence: Dehiscence refers to the partial or total separation of the wound's layers, often occurring after surgery, such as when coughing increases intra-abdominal pressure.

B. Laceration: A laceration refers to a tear or break in the skin due to trauma, not a surgical complication.

C. Evisceration: Evisceration occurs when the internal organs protrude through the wound, which is a more severe complication than dehiscence.

D. Autologous: Autologous refers to using a person's own tissues or cells (e.g., blood transfusion), not a wound complication.

A. urinary tract infections are common at this stage. B. decreased urine output may be a sign of shock. C. a distended bladder is uncomfortable. D. swelling may block the ureters or urethra.

Correct Answer is B

Explanation

A. Urinary tract infections are common at this stage. While urinary tract infections (UTIs) are a potential postoperative complication, monitoring urine output is not primarily for detecting UTIs but for ensuring adequate kidney function and overall circulatory health.

B. Decreased urine output may be a sign of shock. Decreased urine output can be a key indicator of shock, as inadequate perfusion to the kidneys during shock reduces urine production. This is a critical sign of potential hemodynamic instability and warrants immediate attention.

C. A distended bladder is uncomfortable. While a distended bladder can be uncomfortable, monitoring urine output is more about assessing kidney function and detecting issues like dehydration, shock, or kidney failure rather than simply comfort.

D. Swelling may block the ureters or urethra. Swelling may cause urinary retention, but this is less common as a primary concern postoperatively. The primary reason for monitoring urine output is to assess overall circulation and kidney function, not necessarily to monitor for obstruction.

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The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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