A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?
Place the head of the client's bed flat with the client's legs extended.
Apply butterfly strips to approximate the wound edges.
Apply pressure directly to the wound for 15 min.
Place a sterile, saline-soaked dressing on the wound.
The Correct Answer is D
Rationale:
A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.
B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.
C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.
D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.
B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.
C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.
D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.
Correct Answer is D
Explanation
A. Administer fluid bolus immediately when the client arrives to the facility: Rapid fluid boluses are reserved for clients in hypovolemic shock. For burn resuscitation, fluids are calculated and administered according to formulas rather than as a one-time bolus.
B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr: Burn fluid resuscitation formulas, such as the Parkland formula, typically require half of the total calculated fluids to be given within the first 8 hours post-burn, not 12 hours.
C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility: Fluid calculation is based on the time of the burn occurrence, not the arrival time, to ensure accurate resuscitation over the initial 24 hours.
D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation: The extent of burns, expressed as a percentage of total body surface area (TBSA), is a key factor in calculating fluid needs. Accurate TBSA assessment ensures appropriate fluid resuscitation to maintain perfusion and prevent complications.
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