A 65-year-old post-operative patient presents with a sudden opening of their surgical abdominal wound. What is the most appropriate immediate nursing action to take for this patient experiencing wound dehiscence?

Instruct the patient to cough and deep breathe to prevent atelectasis.

Apply a sterile saline dressing and notify the surgeon immediately.

Increase the patient's oral fluid intake to promote healing.

Apply pressure to the wound to stop any bleeding.

Answer and Explanation

The Correct Answer is B

A. Instruct the patient to cough and deep breathe to prevent atelectasis: While coughing and deep breathing are important post-operative interventions to prevent respiratory complications, they are not appropriate actions in the case of wound dehiscence. Encouraging coughing could exacerbate the situation by increasing intra-abdominal pressure.

B. Apply a sterile saline dressing and notify the surgeon immediately: This is the most appropriate immediate action in the event of wound dehiscence. Applying a sterile saline dressing helps protect the exposed tissue and prevent infection, while notifying the surgeon is crucial for further evaluation and intervention. Wound dehiscence is a surgical emergency that requires prompt attention.

C. Increase the patient's oral fluid intake to promote healing: While adequate hydration is important for overall recovery, it is not an immediate action to take in response to wound dehiscence. Addressing the wound itself and notifying the surgical team is the priority in this situation.

D. Apply pressure to the wound to stop any bleeding: While it is important to control bleeding, applying pressure may not be appropriate if there is significant opening or exposure of the internal structures. Instead, the focus should be on covering the wound with a sterile dressing and seeking immediate surgical intervention to assess and manage the dehiscence.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. A nurse gives a client the choice to take a pain medication via intramuscular or oral route: This action exemplifies the ethical principle of autonomy, as it respects the client’s right to make decisions regarding their own treatment options.

B. A nurse administers scheduled pain medication for a client who is having pain: This action reflects the principle of beneficence, which emphasizes the obligation to act in the best interest of the client and alleviate suffering. Administering pain medication according to the schedule supports the client's well-being.

C. A nurse fulfills a promise to a client that they will return with their pain medication: This action demonstrates fidelity, which involves keeping promises and commitments made to clients. It ensures trust and accountability in the nurse-client relationship.

D. A nurse provides nonpharmacological pain interventions to each client equally: This action represents the principle of justice, which emphasizes fairness and equality in the distribution of resources and treatment among clients. Providing equal access to pain interventions ensures that all clients receive appropriate care regardless of their individual circumstances, aligning with the ethical principle of justice.

A. The client is attempting to remove the restraint. B. The client has full range of motion in her wrist. C. The client's hand is cool and pale. D. The client has a capillary refill of less than 2 seconds.

Correct Answer is C

Explanation

A. The client is attempting to remove the restraint: While this may indicate discomfort or agitation, it does not necessarily warrant loosening the restraint. The nurse should assess the underlying reasons for the client's behavior but may need to keep the restraint in place for safety if the client poses a risk to themselves or others.

B. The client has full range of motion in her wrist: Having full range of motion does not indicate a need to loosen the restraint. The primary concern with restraints is ensuring the client's safety and comfort while monitoring for signs of circulation and proper function.

C. The client's hand is cool and pale: This finding is concerning and indicates potential impaired circulation due to the restraint being too tight. Loosening the restraint is essential in this case to restore circulation and prevent further complications. Coolness and paleness are signs of inadequate blood flow and require immediate action to ensure the client’s safety.

D. The client has a capillary refill of less than 2 seconds: A capillary refill of less than 2 seconds typically indicates good circulation. While monitoring capillary refill is important, this finding alone does not warrant loosening the restraint. The priority is to respond to any indications of compromised circulation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 65-year-old post-operative patient presents with a sudden opening of their surgical abdominal wound. What is the most appropriate immediate nursing action to take for this patient experiencing wound dehiscence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of justice?

Correct Answer is D

Explanation

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is C

Explanation

The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)