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 D

Explanation

A. Airborne: Airborne precautions are used for diseases that can be transmitted through airborne droplet nuclei, such as tuberculosis or measles. Hepatitis C is not transmitted through the air, making airborne precautions unnecessary for this condition.

B. Droplet: Droplet precautions are required for infections spread through respiratory droplets, such as influenza or meningitis. Hepatitis C is not spread via respiratory droplets, so droplet precautions are not applicable.

C. Contact: Contact precautions are necessary for infections that can be transmitted through direct contact with the patient or contaminated surfaces, such as MRSA or C. difficile. While contact precautions may be applied in specific situations involving hepatitis C, they are not the standard precautions for routine care of hepatitis C patients.

D. Standard: Standard precautions are the foundation for infection control practices and are recommended for all patients, regardless of their diagnosis. This includes measures such as hand hygiene, using personal protective equipment (PPE) when necessary, and safe handling of potentially contaminated materials. Since hepatitis C is primarily transmitted through blood and body fluids, standard precautions are appropriate for caring for clients with this condition.

A. Turn and reposition the patient every 2 hours. B. Apply hydrocolloid dressing to the pressure injury. C. Change pressure injury dressings every shift. D. Assess the patient's skin condition.

Correct Answer is A

Explanation

A. Turn and reposition the patient every 2 hours: This task can be delegated to nursing assistive personnel (NAP). NAPs are trained to assist with basic patient care tasks, including turning and repositioning patients to prevent pressure injuries and promote comfort.

B. Apply hydrocolloid dressing to the pressure injury: This task should not be delegated to NAPs, as applying dressings requires knowledge of wound care principles and techniques, which falls under the scope of nursing practice.

C. Change pressure injury dressings every shift: Changing dressings is a nursing responsibility that requires assessment and skill in managing wound care. This task should be performed by the nurse to ensure proper technique and evaluate the wound condition.

D. Assess the patient's skin condition: Skin assessment is a nursing responsibility that requires clinical judgment and expertise. The nurse must assess the skin to identify any changes or complications related to pressure injuries, which should not be delegated to NAPs.

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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

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

Correct Answer is D

Explanation

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)?

Correct Answer is A

Explanation

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