A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Check the client's vital signs.

Cover the wound with a moist, sterile gauze dressing.

Assess the client's pain level.

Obtain a culture and sensitivity of the wound drainage

Answer and Explanation

The Correct Answer is B

A. Check the client's vital signs. While vital signs are important for overall assessment, the immediate priority when faced with wound dehiscence is to protect the wound and prevent further contamination or damage.

B. Cover the wound with a moist, sterile gauze dressing. The first priority is to cover the wound with a moist, sterile dressing to protect it from infection and to manage the drainage. This helps in creating a barrier to prevent contamination and supports the wound environment for healing.

C. Assess the client's pain level. Pain assessment is important but not the immediate priority in this case. Managing the wound and preventing further complications is more critical.

D. Obtain a culture and sensitivity of the wound drainage. While obtaining a culture is important to identify any infection, it is not the first action. Protecting the wound from further contamination comes first.

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Correct Answer is B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

A. “I need something for the pain in my eye. I can't stand it." B. "It’s hard to see with a patch on one eye. I'm afraid of falling" C. "My eye really itches, but I'm trying not to rub it." D. "The bright light in this room is really bothering me."

Correct Answer is A

Explanation

A. “I need something for the pain in my eye. I can't stand it." Severe pain after cataract surgery is unusual and could indicate complications such as increased intraocular pressure or infection. This should be reported immediately to the provider for further evaluation.

B. "It’s hard to see with a patch on one eye. I'm afraid of falling": This is a common concern and relates to mobility safety, not a sign of a surgical complication.

C. "My eye really itches, but I'm trying not to rub it.": Itching can be a normal response post-surgery due to healing. Patients should avoid rubbing the eye, and this does not necessarily indicate a complication.

D. "The bright light in this room is really bothering me.": Photophobia or sensitivity to light can be common postoperatively and is usually not a sign of a serious issue.

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A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Nursing Test Bank

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