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. Notifying the provider: This is important but should be done after stopping the transfusion.

B. Stopping the transfusion. Chills and back pain during a blood transfusion can indicate a serious transfusion reaction, such as an acute hemolytic reaction. The priority action is to stop the transfusion immediately to prevent further complications

C. Covering the client with a blanket: This addresses the symptom of chills but does not address the potential life-threatening reaction.

D. Assessing the client's skin for a rash: This is part of the assessment for transfusion reactions but is not the priority compared to stopping the transfusion.

A. impaired skin integrity B. Alteration in activity tolerance C. Impaired tissue perfusion D. Alteration in body image

Correct Answer is C

Explanation

A. Impaired skin integrity - While the patient does have skin issues due to ulcerations, the root cause is impaired perfusion. Addressing the impaired tissue perfusion will help improve skin integrity.

B. Alteration in activity tolerance - Although the patient might experience reduced activity tolerance due to the heaviness and discomfort, it is not as critical as ensuring adequate tissue perfusion.

C. Impaired tissue perfusion - This diagnosis is the priority because varicose veins and ulcerations with lower extremity edema suggest that there is poor blood flow to the tissues, which can lead to further complications such as worsening ulcerations and potential infection. Effective tissue perfusion is critical to healing and preventing further deterioration.

D. Alteration in body image - This is a valid concern for the patient but is not as immediate or life-threatening as impaired tissue perfusion and the potential for complications from poor circulation.

View Question and Answer

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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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

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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