A nurse is assessing a patient post-abdominal surgery and observes serosanguinous drainage on the dressing. What is the most appropriate initial action for the nurse to take?
Change the dressing to maintain aseptic conditions.
move the dressing to examine the wound bed.
Reinforce the dressing and notify the physician
Inspect the drainage for color, odor, and amount.
The Correct Answer is D
A. Change the dressing to maintain aseptic conditions: While dressing changes are important, immediately removing or changing the dressing without assessment may disrupt the wound and impede monitoring of drainage characteristics. Assessment should come first.
B. Move the dressing to examine the wound bed: Lifting or removing the dressing prematurely can expose the wound to infection and trauma. Initial observation should rely on visual inspection through a transparent dressing if possible or minimal disturbance.
C. Reinforce the dressing and notify the physician: Reinforcing the dressing may be appropriate if drainage is heavy, but before notifying the physician, the nurse should first assess and document the drainage characteristics to provide accurate information.
D. Inspect the drainage for color, odor, and amount: Assessing the drainage is the first and most appropriate action. Serosanguinous drainage is expected in the early postoperative period, and documenting its color, odor, and volume helps distinguish normal from abnormal findings and guides subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Proceed with the procedure and apologize later for not accommodating the request: Ignoring the patient’s spiritual needs can increase anxiety, reduce trust, and negatively impact holistic care. Delaying acknowledgment until after the procedure does not respect the patient’s values.
B. Allow the patient uninterrupted time for prayer and reschedule the procedure if necessary: Supporting the patient’s spiritual practices demonstrates respect for their beliefs, promotes emotional well-being, and aligns with holistic, patient-centered care. Temporarily adjusting the treatment schedule ensures the patient’s needs are honored safely.
C. Ask the chaplain to perform the prayer instead of the patient: While chaplain support is valuable, the patient specifically requested personal time for prayer. Substituting the chaplain does not respect the patient’s autonomy or individual spiritual practice.
D. Inform the patient that spiritual practices must be completed after the procedure: Deferring spiritual practices unnecessarily can increase stress and anxiety, potentially impacting the patient’s comfort and cooperation. Accommodation prior to treatment is safer and more supportive.
Correct Answer is D
Explanation
A. Provide a detailed explanation of the risks to the client: Nurses can clarify general information but are not responsible for providing in-depth explanations of procedure-specific risks, which is the provider’s responsibility. Overstepping may lead to misinformation.
B. Refer the client to a medical interpreter for clarification: An interpreter is appropriate if a language barrier exists. However, confusion in understanding the risks does not automatically indicate a language issue, this may not address the underlying concern.
C. Ask the client to sign the consent form and proceed with the procedure: Obtaining consent when the client does not fully understand the risks is unethical and legally inappropriate. Consent must be informed and voluntary before proceeding.
D. Notify the provider and request further clarification for the client: The provider is legally and professionally responsible for ensuring the client fully understands the procedure and its risks. Alerting the provider allows the client to receive accurate information, supporting informed consent and patient safety.
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