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.

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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.

A. "I should get a longer cord for my telephone." B. "I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "It is a good idea to use the handrails in the bathroom."

Correct Answer is D

Explanation

A. "I should get a longer cord for my telephone.": Longer cords can create tripping hazards, increasing the risk of falls. It is safer to use shorter cords or secure them properly to minimize risks. Keeping cords neatly organized and out of walkways is essential for maintaining a safe environment.

B. "I should use chairs without armrests.": Chairs with armrests can provide additional support for getting in and out of the chair, which can help prevent falls. Using chairs without armrests may make it more difficult to rise safely and could lead to losing balance during the process.

C. "I should place a throw rug over electrical cords.": Throw rugs can create tripping hazards. Placing rugs over electrical cords does not eliminate the risk and could further increase the likelihood of a fall. It's important to keep the area clear of both rugs and cords to promote safety and prevent accidents.

D. "It is a good idea to use the handrails in the bathroom.": Handrails provide stability and support when navigating potentially slippery areas, such as bathrooms, and can significantly reduce the risk of falls. Utilizing handrails allows individuals to maintain their balance and provides reassurance when moving in and out of the tub or shower.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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