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 B

Explanation

A. To increase blood flow to the wound site: While debridement may indirectly help improve blood flow by removing barriers to healing, its primary purpose is not to increase blood flow. Increased blood flow is a result of improved wound bed conditions rather than the main goal of the procedure.

B. To remove necrotic tissue to promote healing: The primary purpose of wound debridement is to remove necrotic (dead) or devitalized tissue from the wound bed. This process promotes healing by creating a clean wound environment, facilitating granulation tissue formation, and reducing the risk of infection, making this option the most accurate.

C. To apply antibiotics directly to the wound: While antibiotics may be part of the overall wound care plan, debridement itself is not intended for the direct application of antibiotics. The focus is on removing non-viable tissue rather than applying medications during the procedure.

D. To prevent scar formation: While proper wound care, including debridement, can help improve healing outcomes and potentially minimize scarring, the primary aim of debridement is not to prevent scars. Scarring is influenced by multiple factors, including the type of wound, depth, and individual healing responses.

A. Vigorously brush the client's teeth. B. Hold the toothbrush at a 90° angle. C. Place two fingers in the client's mouth. D. Turn the client to the side.

Correct Answer is D

Explanation

A. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

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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

In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

Correct Answer is B

Explanation

A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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