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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Patient has chest pain. Needs to see a doctor.: This entry is vague and lacks essential subjective and objective data. It does not include the client’s own words, pain characteristics, or vital signs. Narrative charting requires detailed, specific, and measurable information.

B. Patient states, “I suddenly felt a sharp pain in my chest while gardening.” Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg. Heart rate: 100 beats/min, regular.: This entry includes subjective data in the client’s own words, objective assessment findings, and relevant vital signs. It clearly documents onset, quality, severity, and associated findings. This reflects accurate, complete, and legally sound narrative charting.

C. The patient was gardening when they got chest pain. Blood pressure high: This statement lacks specific pain description, numeric values, and patient-reported details. Terms such as “high” are non-measurable and imprecise. Incomplete data limits clinical usefulness.

D. The patient felt pain in the chest while in the garden. No further information provided.: This entry is incomplete and omits critical assessment details such as pain severity, vital signs, and associated symptoms. Narrative charting must provide sufficient information to guide clinical decision-making.

A. Full-thickness skin loss exposing adipose tissue but not bone or muscle. B. Nonblanchable erythema of intact skin. C. Partial-thickness skin loss with exposed dermis. D. Localized, nonblanchable, deep red, maroon, or purple discoloration of intact skin

Correct Answer is D

Explanation

A. Full-thickness skin loss exposing adipose tissue but not bone or muscle: This finding is characteristic of a Stage III pressure injury, not a deep tissue injury. Stage III involves actual tissue loss rather than injury limited to underlying tissues beneath intact skin.

B. Nonblanchable erythema of intact skin: This finding indicates a Stage I pressure injury, which involves superficial skin changes without tissue necrosis. It does not reflect deep tissue involvement.

C. Partial-thickness skin loss with exposed dermis: This is consistent with a Stage II pressure injury, involving partial-thickness loss of epidermis or dermis. It does not indicate damage to underlying soft tissue beneath intact skin.

D. Localized, nonblanchable, deep red, maroon, or purple discoloration of intact skin: Deep tissue injury is identified by damage to underlying soft tissue beneath intact skin, often presenting as deep red, maroon, or purple areas. This finding reflects the hallmark sign of deep tissue injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting a patient's condition in a narrative chart. The patient reports sudden onset chest pain while gardening Which of the following chart entries best exemplifies accurate and complete narrative charting?

Correct Answer is B

Explanation

A nurse is assessing a patient with suspected deep tissue injury on the sacral area. Which finding would most likely confirm this diagnosis?

Correct Answer is D

Explanation

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